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Health Information Management Essay | Online Homework Help

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
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

Effective Date
Thorough description of the policy
Definition of Terms (associated with policy)
Consequences for Failure to Comply


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


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