Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)

Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)

Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much-needed policies to govern the practice of health record documentation within your organization. You must devise two (2) of these policies, adhering to the format listed below and using APA formatting with sub-headings. Submit one (1) single Microsoft Word document.

Deliverables: Create two (2) policies to address electronic health record documentation. You must select from the following list of topics:

The Use of Electronic signatures/Authentication
Legibility
Electronic Health Record Duplication
Health Record Amendments
The Completion of Health Records (adhering to TJC timeline)…including 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, including Training & Education and Password Protection and Updates
Copy & Paste Functionality
Cloned Documentation
Templates/Screen Designs

Health Record Policy Format:

Subject
Purpose
Staff
Effective Date
A thorough description of the policy
Definition of Terms (associated with policy)
Procedure
Consequences for Failure to Comply

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/ANAMarketplace/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

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