Health Record Documentation Policy

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:The Use of Electronic signatures/AuthenticationLegibilityElectronic Health Record DuplicationHealth Record AmendmentsThe Completion of Health Records (adhering to the JC timeline)this includes the various forms (components within the Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)Verbal & Telephone OrdersThe use of departmental/organizational wide abbreviationsThe Physician Query ProcessThe Use of MACRA& Meaningful Use (MU) AuditsAuthorized UsersTraining & EducationPassword Protection and UpdatesCopy & Paste FunctionalityCloned DocumentationTemplates/Screen DesignsHealth Record Policy Layout Format:SubjectPurposeStaffEffective DateA thorough description of the policyDefinition of Terms (associated with policy)ProcedureResources:Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update): of the Legal Health Record and Designated Record Set: Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: & MU: http://www.fiercehealthcare.comSample Compliance Checklists for Electronic Health Records: Health Organization: GUIDANCE ON GOOD DATA AND RECORD MANAGEMENT PRACTICES:

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