Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation.
As the recently hired Corporate Director of Health Information Management you have tasked the assignment of creating a much needed policies to govern the practice of health record documentation. You have appointed your HIM Manager to devise such policies adhering to the format listed below. Submit one (1) single presentation.
Deliverables:Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation. Select from the following list of topics to choose from:
Health Record Policy Layout Format:
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
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