As the HIM documentation supervisor, you are meeting with the quality improvement (QI) manager to assist in developing an audit template to be used for a quality review of patient record.

Select one of the following documents

1. History and physical
2. Operative reports
3. Discharge summary

Using the Joint Commission website and your textbook, research the standards for your selected document.

Develop a list of required data elements that would be included in the development of an audit data collection tool, inclusive of the time requirement for completion.

• The initial response must be relevant, detailed, and specific, at least 250 words.