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 policiesadhering to the formatlisted below. Submitone (1) single presentation.
Deliverables:Create a total of two (2) policies to addresselectronic 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