Assignment:Health Record Documentation Policy

Assignment:Health Record Documentation Policy

Assignment:Health Record Documentation Policy

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Health Record Documentation Policy
As the recently hired Corporate Director of Health Information Management, you have tasked the assignment of creating a much needed policies to govern the practice of health record documentation. You have appointed your HIM Manager to devise such policies adhering to the format listed below. Submit one (1) single presentation.

Deliverables: Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation. Select from the following list of topics to choose from:

The Use of Electronic signatures/Authentication
Legibility
Electronic Health Record Duplication
Health Record Amendments
The Completion of Health Records (adhering to the JC timeline)
this includes the various forms (components within the Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)
Verbal & Telephone Orders
The use of departmental/organizational wide abbreviations
The Physician Query Process
The Use of MACRA& Meaningful Use (MU) Audits
Authorized Users
Training & Education
Password Protection and Updates
Copy & Paste Functionality
Cloned Documentation
Templates/Screen Designs
Health Record Policy Layout Format:

Subject
Purpose
Staff
Effective Date
A thorough description of the policy
Definition of Terms (associated with policy)
Procedure
Resources:

Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update): http://library.ahima.org/doc?oid=300257#.WHkS_lVpHIV

Fundamentals of the Legal Health Record and Designated Record Set: http://library.ahima.org/doc?oid=104008#.WHkTVFVpHIU

Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html

MACRA & MU: http://www.fiercehealthcare.com

Sample Compliance Checklists for Electronic Health Records: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-compliance-checklist.pdf

World Health Organization: GUIDANCE ON GOOD DATA AND RECORD MANAGEMENT PRACTICES: http://www.who.int/medicines/areas/quality_safety/quality_assurance/Guidance-on-good-data-management-practices_QAS15-624_16092015.pdf

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

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