The new director of health information management has been appointed for the Apex Health System. Apex Health System was recently formed when three hospitals began operations under one corporation. Two of the facilities are located in Capital City and the third hospital is located 50 miles away. The two hospitals in Capital City use the same medical staff as they see patients at both facilities. After a review of the medical staff bylaws, the new HIM director realizes that the health record completion standards in the bylaws are different for each facility. Even though all of the hospitals are using the same computerized provider order entry system (CPOE), some facilities require physicians to use the CPOE system and others allow physicians to write orders. The director needs to make a recommendation concerning record completion at the newly formed systems-level Health Information Services committee meeting. The major question is whether record completion guidelines, including sanctions for non-compliant medical staff members, should be the same for all three facilities.
1. Describe the resources that should be reviewed to make a valid recommendation to the committee.
2. If disciplinary action is to occur for non-compliance how should due process be handled?