health records documentation and storage
730.9.4 : Health Information Standards and Regulations for Documentation
The graduate ensures compliance with governing agency policies for health records documentation and storage.
Health information management (HIM) professionals may be responsible for managing policies and processes in order to ensure organizational readiness for accreditation, licensing, and certification processes. HIM professionals must have a thorough understanding of accreditation processes and know where to locate information when it is needed.
As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer regarding history and physical (H&P) documentation compliance. Cedar Bend is doing a system update of its electronic health record (EHR), and there are new design capabilities with regard to how history and physical assessments are documented in the hospital. There are concerns that stakeholders have ideas of how the new EHR system should function with regard to history and physical documentation, but that there is a lack of understanding as to the applicable regulatory requirements. The purpose of the meeting is to make sure the policy and procedure that address history and physical documentation are both current with regard to The Joint Commission (TJC) and state requirements.
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Create a multimedia presentation (e.g., PowerPoint, Keynote) (suggested length of 8â€“16 slides) for your HIM director and chief medical officer (CMO) to summarize your analysis of history and physical (H&P) documentation compliance. Include presenter notes for each slide (suggested length of 1â€“2 paragraphs of notes per slide).
Note: Please base your analysis of state regulations on the current state in which you live. If your state does not have specific regulations, you may choose another state that does. Use information provided in the â€œState Regulationsâ€ attachment and â€œThe Joint Commission Standards Interpretationâ€ web link for your analysis. Other sources can be used as well.
1. Include a title slide that presents your name and the state in which you reside or the state you have chosen to base your analysis on.
2. Include a slide with a table that lists the similarities between The Joint Commission (TJC) standards and your chosen stateâ€s regulations regarding history and physical (H&P) documentation requirements.
3. Include a slide with a table that shows the differences between The Joint Commission standards and your chosen stateâ€s regulations regarding history and physical (H&P) documentation requirements.
4. Include at least one slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the EHR.
5. Include at least one slide that shows The Joint Commission standardsâ€ required time frames to complete the history and physical (H&P) documentation with regard to standard medical admissions, readmissions, and surgical admissions.
6. Include at least one slide that shows the importance of documenting the patientâ€s chief complaint as part of the medical history.
7. Include at least one slide that shows a list of recommendations for your EHR system to comply with both sets of standards.
8. Include at least one slide describing how your organization can monitor and stay current with national and state regulations.
B. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
File name may contain only letters, numbers, spaces, and these symbols: ! – _ . * ‘ ( )File size limit: 200 MBFile types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z
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