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historyrevise.docxPOLICY ON DOCUMENTATION REQUIREMENTS IN THE HEALTH RECORD 1
POLICY ON DOCUMENTATION REQUIREMENTS IN THE HEALTH RECORD 6
Policy on Documentation Requirements in the Health Record
Policy on Documentation Requirements in the Health Record
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TITLE:
POLICY WRITING ON DOCUMENTATION REQUIREMENTS IN THE HEALTH RECORD |
DEPT: HIM SERVICES
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SUBMITTED BY:
DATE: 06/01/18 |
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APPROVED BY:
DATE: 06/01/18 |
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Effective Date: 06/03/18
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Purpose
To provide a guide to writing and maintaining effective and uniform policies and procedures for a HIM Services Department.
Policy
EHR (Health Record) content shall comply with standards established by JCAHO (Joint Commission on Accreditation of Health Care Organizations) and AHIMA (American Health Information Management Association) and shall also comply with requirements in third-party payment programs or with licensure requirements of special programs. All patient care documentation will be entered by provider data entry, transcription, uploading, and document scanning.
Procedure
1. Health records will have adequate information that can easily identify the patient, show the diagnosis that was done to him or her alongside all the results that were obtained. The record should also have a section that outlines the condition of the patient when he or she was discharged and a detailed instruction that is directed to the patient in regards to follow up care, activity levels and all the necessary medication that the patient ought to take in addition to the given prescription.
2. All the entries made on the document must be accurate. This can be ensured by having different people countercheck the entries.
3. The accuracy of the document will be determined based on different aspects including relevance, timely and completeness.
4. Only relevant information to be included in patient’s documents. The documentation of a patient’s record should always be free from any irrelevant information.
5. If there are any notes made to the document, appropriate note titles must be matched to note content and the credentials of the author. This enhances the ability to find a note more quickly and easily. This would also enable the enhancement of accountability as these notes must be signed by the one who wrote them.
Health record users must react rapidly to notices, which incite them of reports requiring validation or extra data.
6. The electronic function of duplication must be utilized with caution and as indicated by strict and enforceable approach.
· Never duplicate a user’s signature.
· Never duplicate information or data that distinguishes a medicinal services supplier as associated with mind that he/she isn't engaged with.
· Do not duplicate whole research center discoveries, radiology reports and other data in the record verbatim into a note. Information duplicated must be particular and germane to the care gave.
· Do not re-enter beforehand recorded information.
7. Authentication incorporates the character and expert teach of the creator, the date, and the time marked. Notes made and verified by human services colleagues must be exclusively recognized either by the utilization of the person's title, or by the proper accreditation assignment. On attached, confirmation on electronic records can't be repealed or withdrawn.
8. No alter or adjustment of any documentation or electronic mark, which has been finished, can happen without endorsement of the HIM Director.
9. The creator must start any withdrawal or rescission of any passage or beginning order, i.e., lab and radiology are cases of orders that may start withdrawals or rescissions inside their bundles.
10. The electronic function of duplication must be utilized with caution and as indicated by strict and enforceable approach.
· Never duplicate a user’s signature
· Never duplicate information or data that distinguishes a medicinal services supplier as associated with mind that he/she isn't engaged with
· Do not duplicate whole research center discoveries, radiology reports and other data in the record verbatim into a note. Information duplicated must be particular and germane to the care gave
· Do not re-enter beforehand recorded information.
11. Authentication incorporates the character and expert teach of the creator, the date, and the time marked. Notes made and verified by human services colleagues must be exclusively recognized either by the utilization of the person's title, or by the proper accreditation assignment. On attached, confirmation on electronic records can't be repealed or withdrawn.
12. No alter or adjustment of any documentation or electronic mark, which has been finished, can happen without endorsement of the HIM Director.
13. The creator must start any withdrawal or rescission of any passage or beginning order, i.e., lab and radiology are cases of orders that may start withdrawals or rescissions inside their bundles.
overall good work. However, make sure that you specifically name the H&P in your policy. It appears as though it is solely about record documentation rather than documenting the H&P.
References
Creighton Health Sciences School Policy_ Patient Rights and Responsibilities
Kansas County Health Department- Medical Records Policy
