Health Record Documentation

Description

Instructions

ASSIGNMENT: Create Health Information Documentation Guidelines

CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation

• Compile organization-wide health record documentation guidelines

Scenario: You are the new HIM Director for Community Healthcare which includes an acute care hospital, an attached clinic and an attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines.

You first need to compile the guidelines set forth by Joint Commission and CMS since those are the regulatory bodies that monitor your organization.

Instructions:

1. Locate the documentation standards for the Joint Commission and CMS and Conditions of Participation.
2. Create a table listing medical record documentation standards for both the Joint Commission and CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic, and Longterm Care). You will have 3 tables, one for each type of facility.
3. Title the document as a policy and write a short explanation of the purpose of the document and how it should be used.
4. ASSIGNMENT: Secondary Data Sources
5. CAHIIM Competency: Subdomain I.E. Secondary Data Sources
   • Validate data from secondary sources to include in the patient’s record, including personal health records
   • Preparation: Read the Processing and Maintenance of Secondary Databases section of Chapter 6 in the Oachs and Watters text. (Page 191-193 in the 5th edition)While the reading focusses on data from patient health records being abstracted or moving electronically into secondary data source systems, more and more we are having to consider data from secondary data sources being used to add to the primary health record. Examples:
   1. A patient brings in their personal health record that contains health information from 2 other primary care providers at local clinics. They want this information added to their health record at your hospital.
   2. Inbound HIE data from an earlier encounter from an unrelated provider is electronically received for a patient’s health records
   3. Inbound data from the patient portal is received many times a day as patients update their demographic or insurance information on the patient portal
   4. Data is received from smart devices such as ambulatory heart monitors or insulin monitors and is downloaded into patient records
   5. It would be inefficient for all of this inpatient data to be manually checked for validity. Please describe in 2-3 paragraphs (400-500 words) how a healthcare organization could assure that this incoming data is valid and accurate. Be sure to specifically address how systems would be set up, as well as standards and policies that would need to be set.