Description
Week Three: Health Record Documentation Policy
Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked with the assignment of creating policies to govern the practice of health record documentation in your organization. You must devise two (2) policies adhering to the format (Health Record Policy Format) listed below using APA formatting with sub-headings.
Deliverables: Create two (2) policies to address electronic health record documentation. You must select topics from the following list:
- The Use of Electronic signatures/Authentication
- Legibility
- Electronic Health Record Duplication
- Health Record Amendments
- 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 department/organization-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:
The 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
Sample Compliance Checklists for Electronic Health Records: https://kyma.org/shared/content/uploads/2015/12/ehr-compliance-checklist.pdf
Explanation & Answer
View attached explanation and answer. Let me know if you have any questions.
1
POLICY
Health Record Documentation Policy
Name
Institution
Course
Instructor
Due Date
2
POLICY
Health Record Documentation Policy
Electronic Health Record Duplication
1. Subject.
Minimizing health records duplication through the use of biometrics.
2. Purpose.
This policy aims to offer a potential solution for minimizing EHRs duplication, which has been a
growing concern as it can result in compromised data accuracy, medical care, patient safety, and
reimbursement. The use of biometrics offers an effective approach for solving, preventing and
managing duplicate medical record issues.
3. Staff.
This policy applies to all registration employees who are tasked with creating and/or updating
patients’ records, including the Medical Records Manager, who is tasked with managing and
overseeing the medical records function within the healthcare organization.
4. Effective Date.
This policy will come into effect on April 1, 2022. This provides ample time for registration
employees to receive the needed training for incorporating patients’ biometrics in health records.
5. A thorough description of the policy.
Documentation integrity is considered a critical aspect in healthcare as it refers to the accuracy of
the complete health record (AHIMA Work Group, 2013). Caregivers rely on the information
contained in health records to inform their decisions, hence the need to incorporate effective
3
POLICY
safeguards to ensure the information contained in the records is accurate. Duplicate medical
records are a common data quality issue that threatens documentation integrity, and jeopardizes
the quality of care offered to patients (Harris & Shannon, 2018). However, rapid advances in
technology have provided organizations with new solutions and tools for ad...