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/AuthenticationLegibilityElectronic Health Record DuplicationHealth Record AmendmentsThe 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 OrdersThe use of departmental/organizational wide abbreviationsThe Physician Query ProcessThe Use of MACRA & Meaningful Use (MU) AuditsAuthorized Users, including Training & Education and Password Protection and UpdatesCopy & Paste FunctionalityCloned DocumentationTemplates/Screen Designs
Health Record Policy Format:
SubjectPurposeStaffEffective DateA thorough description of the policyDefinition of Terms (associated with policy)ProcedureConsequences 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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