ASSIGNMENT: Create Health Information Documentation Guidelines
CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation
• Compile organization-wide health record documentation guidelines
Review the assignment instructions below, and each of the deliverables:
Scenario: You are the new HIM Director for Community Healthcare which includes an 1) acute care hospital, an 2) attached clinic and an 3) attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines.
You first need to compile the guidelines set forth by the CMS since those are the regulatory bodies that monitor your organization.
Instructions:
1. Locate the documentation standards for the CMS Conditions of Participation.
2. Create a table listing medical record documentation standards for CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic (RURAL HEALTH), and Longterm Care). You will have 3 tables, one for each type of facility. See the websites for each type of facility for your table.
Format your assignment according to the following formatting requirements:
1. The answer should be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides.
2. The response also include a cover page containing the title of the assignment, the student's name, the course title, and the date. The cover page is not included in the required page length.
3. Also Include a reference page. The Citations and references should follow APA format. The reference page is not included in the required page length.