List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices.

1. Accurate Patient Identification: Patient identification should be established and verified prior to admission, transfer or discharge in order to ensure that the medical record is associated with the correct patient. This can include verifying name, date of birth and other unique identifiers.

2. Complete Documentation: All appropriate documentation related to a patient’s care should be included in their health record including demographics, progress notes, test results, treatments and medications prescribed. This ensures that all relevant information is available for current and future healthcare providers when making decisions about a patient’s care.

3. Legible Documentation: Handwritten documents must be legible in order for another provider to understand what was written; this also applies if the document is scanned into an electronic system where it will likely still need to be read by another person at some point.

4. Timeliness of Documentation: In order for data to remain accurate within a health record, entries must be made promptly following any changes in the care plan or treatment given as well as any significant observations of the patient’s condition/progress during their stay at a facility or while under homecare services (if applicable).

5. Consistent Nomenclature: For medical records to make sense across different providers they must use consistent terminologies such as International Classification of Diseases codes (ICD) coding systems so that everyone has access to similarly structured data making diagnoses easier to compare between providers and time frames more accurately tracked when needed.

6 Quality Assurance Measures: In order for organizations/agencies providing CDI programs to maintain high quality standards they need establish measures/processes which monitor accuracy of data entered into health records and promote complete documentation from all involved parties ensuring that nothing relevant is missed out on from either side (such patients or clinicians). Regular training sessions regarding these policies can help ensure compliance amongst staff members both old and new alike.