training compliance with governing agency policies for health records documentation and storage 1

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Background Information:

Health information management (HIM) professionals may be responsible for managing policies and processes in order to ensure organizational readiness for accreditation, licensing, and certification processes. HIM professionals must have a thorough understanding of accreditation processes and know where to locate information when it is needed.

As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer regarding history and physical (H&P) documentation compliance. Cedar Bend is doing a system update of its electronic health record (EHR), and there are new design capabilities with regard to how history and physical assessments are documented in the hospital. There are concerns that stakeholders have ideas of how the new EHR system should function with regard to history and physical documentation, but that there is a lack of understanding as to the applicable regulatory requirements. The purpose of the meeting is to make sure the policy and procedure that address history and physical documentation are both current with regard to The Joint Commission (TJC) and state requirements.

Requirements:

A. Create a PowerPoint for your HIM director and chief medical officer (CMO) to summarize your analysis of history and physical (H&P) documentation compliance. Include presenter notes for each slide (suggested length of 1–2 paragraphs of notes per slide).

Note: Please base your analysis of state regulations on the current state in which you live. (Iowa) If your state does not have specific regulations, you may choose another state that does. Use information provided in the “State Regulations” attachment and “The Joint Commission Standards Interpretation” web link for your analysis. Other sources can be used as well.

1. Include a title slide that presents your name and the state in which you reside or the state you have chosen to base your analysis on.

2. Include a slide with a table that lists the similarities between The Joint Commission (TJC) standards and your chosen state’s regulations regarding history and physical (H&P) documentation requirements.

3. Include a slide with a table that shows the differences between The Joint Commission standards and your chosen state’s regulations regarding history and physical (H&P) documentation requirements.

4. Include at least one slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the EHR.

5. Include at least one slide that shows The Joint Commission standards’ required time frames to complete the history and physical (H&P) documentation with regard to standard medical admissions, readmissions, and surgical admissions.

6. Include at least one slide that shows the importance of documenting the patient’s chief complaint as part of the medical history.

7. Include at least one slide that shows a list of recommendations for your EHR system to comply with both sets of standards.

8. Include at least one slide describing how your organization can monitor and stay current with national and state regulations.

B. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

https://www.jointcommission.org/standards_informat…

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