Health Record Documentation Policy
Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much needed policies to govern the practice of health record documentation within your organization.
You must devise two (2) of these policies, adhering to the format listed below and using APA formatting with sub-headings.
Deliverables:
• Create two (2) policies to address electronic health record documentation. You must select from the following list of topics:
o The Use of Electronic signatures/Authentication
o Legibility
o Electronic Health Record Duplication
o Health Record Amendments
o The 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.)
o Verbal & Telephone Orders
o The use of departmental/organizational wide abbreviations
o The Physician Query Process
o The Use of MACRA & Meaningful Use (MU) Audits
o Authorized Users, including: Training & Education and Password Protection and Updates
o Copy & Paste Functionality
o Cloned Documentation
o 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:
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
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 & MU: http://www.fiercehealthcare.com
Sample Compliance Checklists for Electronic Health Records: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/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