17 Jul HEALTH RECORD DOCUMENTATION POLICY
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
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