Please no plagiarism
You can use those resources cited below
A Policy = a strategy or specific approach to a specific concern; a principle of action
A Procedure = a series of actions to be taken; an official way to doing something
Week Three: Health Record Documentation Policy
Scenario: 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.
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): https://library.ahima.org/doc?oid=300257#.WHkS_lVpHIV
Fundamentals of the Legal Health Record and Designated Record Set: https://library.ahima.org/doc?oid=104008#.WHkTVFVpHIU
Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: https://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: https://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: https://www.who.int/medicines/areas/quality_safety/quality_assurance/Guidance-on-good-data-management-practices_QAS15-624_16092015.pdf