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 create/devise two (2) policies adhering to the format (Health Record Policy Format) listed below using APA formatting with sub-headings. Submit as a Microsoft Word document
Deliverables: Create two (2) policies to address electronic health record documentation. You must select two (2) topics from the following list, one for each policy:
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: Create your two policies using this format only
Subject
Purpose
Staff
Effective Date
Thorough description of the policy
Definition of Terms (associated with policy)
Procedure
Consequences 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
Appropriate Use of the Copy and Paster Functionality in Electronic Health Records http://bok.ahima.org/PdfView?oid=300306
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: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
MU: https://www.cdc.gov/ehrmeaningfuluse/introduction.html
Sample Compliance Checklists for Electronic Health Records: https://kyma.org/shared/content/uploads/2015/12/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
