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March 20, 2024

Health Records Documentation & Storage

Health Records Documentation & Storage

COMPETENCIES 730.9.4 : Health Information Standards and Regulations for Documentation The graduate ensures compliance with governing agency policies for health records documentation and storage.

Introduction

Health information management (HIM) professionals may be responsible for managing policies and processes in order to ensure organizational readiness for accreditation, licensing, and certification processes. HIM professionals must have a thorough understanding of accreditation processes and know where to locate information when it is needed.

Health Records Documentation & Storage

 Scenario

As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer (CMO) regarding history and physical (H&P) documentation compliance. Cedar Bend is doing a system update of its electronic health record (EHR), and there are new design capabilities with regard to how H&P assessments are documented in the hospital. There are concerns that stakeholders lack understanding of how the new EHR system should function with regard to H&P documentation and the applicable regulatory requirements. The purpose of the meeting is to make sure Cedar Bend’s policies and procedures that address H&P documentation are current with regard to The Joint Commission (TJC) and state requirements.

Health Records Documentation & Storage

Requirements

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The similarity report that is provided when you submit your task can be used as a guide. You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course

Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc., unless specified in the task requirements. All other submissions must be file types that are uploaded and submitted as attachments (e.g., .docx, .pdf, .ppt). A. Create a multimedia presentation (e.g., PowerPoint, Keynote) (suggested length of 8–16 slides) for your HIM director and CMO analyzing H&P documentation compliance. Note: Base your analysis of state regulations on the current state in which you live. If your state does not have specific regulations, you may choose another state that does.

Health Records Documentation & Storage

Include a title slide that includes your student ID and the state you have chosen to base your analysis on. Include a slide with a table that compares the similarities between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide with a table that compares the differences between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the H&P, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that describes TJC standards time frames to complete the H&P documentation with regard to standard admissions, surgical admissions, or readmissions, including presenter notes (suggested length of 1–2 paragraphs).

Health Records Documentation & Storage

Include a slide that shows the importance of documenting the patient’s chief complaint as part of the medical history, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that shows a list of recommendations for your EHR system to comply with both sets of standards for H&P documentation, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide describing a plan for how your organization can monitor and stay current with national and state regulations, including presenter notes (suggested length of 1–2 paragraphs).

Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

Demonstrate professional communication in the content and presentation of your submission. Use APA referencing style.