Health Record Documentation Policy

Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much needed policies to govern the practice of health record documentation. You must devise two of these policies, adhering to the format listed below and using APA formatting with sub-headings. This is an individual assignment.

Deliverables: Create two (2) policies to address electronic health record documentation. You must select from the following list of topics:

• The Use of Electronic signatures/Authentication
• Legibility
• Electronic Health Record Duplication
• Health Record Amendments
• The Completion of Health Records (adhering to TJC timeline)...including 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, including: Training & Education and Password Protection and Updates
• Copy & Paste Functionality
• Cloned Documentation
• Templates/Screen Designs

Health Record Policy Format:

• Subject
• Purpose
• Staff
• Effective Date
• A thorough description of the policy
• Definition of Terms (associated with policy)
• Procedure