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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.
Submit one (1) single presentation.
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):
http://library.ahima.org/doc?oid=300257#.WHkS_lVpHIV
Fundamentals of the Legal Health Record and Designated
Record Set:
http://library.ahima.org/doc?oid=104008#.WHkTVFVpHIU
Health Information Technology, Patient Safety, and
Professional Nursing Care Documentation in Acute Care
Settings:
http://www.nursingworld.org/MainMenuCategories/ANAMarket
place/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-
May-2015/Articles-Previous-Topics/Technology-Safety-and-
Professional-Care-Documentation.html
MACRA & MU:
http://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:
http://www.who.int/medicines/areas/quality_safety/quality_assu
rance/Guidance-on-good-data-management-practices_QAS15-
624_16092015.pdf
As the recently hired Corporate Director of Health Information Manag.docx

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  • 1. 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. Submit one (1) single presentation. 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
  • 2. 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): http://library.ahima.org/doc?oid=300257#.WHkS_lVpHIV Fundamentals of the Legal Health Record and Designated Record Set: http://library.ahima.org/doc?oid=104008#.WHkTVFVpHIU Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: http://www.nursingworld.org/MainMenuCategories/ANAMarket place/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2- May-2015/Articles-Previous-Topics/Technology-Safety-and- Professional-Care-Documentation.html MACRA & MU: http://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: http://www.who.int/medicines/areas/quality_safety/quality_assu rance/Guidance-on-good-data-management-practices_QAS15- 624_16092015.pdf