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/Authentication

Legibility

Electronic Health Record Duplication

Health Record Amendments

The 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 Orders

The use of departmental/organizational wide abbreviations

The Physician Query Process

The Use of MACRA& Meaningful Use (MU) Audits

Authorized Users

Training & Education

Password Protection and Updates

Copy & Paste Functionality

Cloned Documentation

Templates/Screen Designs

Health Record Policy Layout Format:

Subject

Purpose

Staff

Effective Date

A thorough description of the policy

Definition of Terms (associated with policy)

Procedure