Health care organization must have in place policies on the documentation requirements for the entire health record. HIM professionals are responsible for ensuring that the requirements are followed so that the healthcare facility is in compliance with the state and federal laws, accreditation and the Medicare Conditions of Participation (CoP). One vital piece of clinical data in the medical record is the history and physical report.
It is imperative that the healthcare facility establishes and follows documentation and completion guidelines for the H&P. For this portion of the policy manual you are required to assess the Documentation Requirements for a health information documentation policy with a focus on the history and physical portion of the policy as an example.
Developing the policy that relates to the documentation in a history and physical will allow you to evaluate the requirements of the policy that would encompass the entire record.
Select policies, procedures and guidelines provided for benchmarking in under Benchmarking Resources based on appropriateness to this topic, or you may research policies, guidelines and standards on your own to use as a benchmark.
Review your selected policies, procedures and guidelines and select the information after comparing those resources that you will include in your policy and write your policy on documentation requirements in the history and physical. Note that the some of the benchmarking policies provided do cover the documentation requirements for the entire record, as an example.
The completed typed policy should be 2pages. If you use a source for the policy, state the source at the end of the policy under a heading titled references.
Requirements
Policy includes appropriate, thorough, and detailed guidelines for H&P documentation. Utilize some Medicare standards for this policy
Applies correct spelling, grammar and a consistent policy format is used.
This week we are continuing to write our policies! The policy for this week focuses on documentation in the health record for the History & Physical.
By now, you all know how to research this information and include information within your own policy based on what you have researched. However, you may want to utilize some Medicare standards for this policy.