Health Record Documentation Policy

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/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: GUIDANCE ON GOOD DATA AND RECORD MANAGEMENT PRACTICES: http://www.who.int/medicines/areas/quality_safety/quality_assurance/Guidance-on-good-data-management-practices_QAS15-624_16092015.pdf