Policy on Authentication

As a healthcare facility it is critical that the organization’s policies be reviewed and or rewritten to reflect changes occurring in the industry. Authentication policies can address the paper record, the electronic health record or both in the very common hybrid system. Detailed policies are required due to the variety of sources of patient record information and the large number of entries made by different healthcare providers in the patient’s record on a daily basis. There are several methods to ensure that the author of the entry in the medical record and entry itself has been validated which are: medical staff bylaws, rules, and regulation and state/federal laws.

For this assignment you are required to compare and contrast the two polices provided in the Module 01 Benchmarking Resources- (County Health Department-Medical Record Policy: Kansas and Banner Health Policy) and evaluate them against sample set of standards from the Illinois Licensing Requirements document. Remember you are to only focus on authentication. Review the required selected policies and standards and select the information after comparing those resources that you will include in your policy and write your policy on organization wide guidelines on authentication in the health record.

The completed typed policy should be 1 page. If you use a source for the policy, state the source at the end of the policy under a heading titled references.

Project Overview-Benchmarking Resources

Benchmarking against other organizations polices and/or available guidelines is an important step in the process of developing or revising polices and guidelines for a healthcare organization. Below is a list of benchmarking resources links to policies and guidelines and standards which relate to the topics you will be preparing policies for during the course project. You may select from the list for sources you would use to benchmark in each module and cite those that you use as a reference at the end of your policy or you may research policies, guidelines and standards on your own to use as a benchmark.

Banner Health “Documentation Requirements for the Medical Record-Policy and Procedure

Pennsylvania Hospital & Surgery Center Administrative Policy Manual - Medical Record Documentation Practices

Kansas County Health Department- Medical Records Policy

Joint Commission - “Do Not Use” List

UTMB Policy Manual

UTMB Health Procedure - Prohibited Abbreviations

UTMB Handbook of Operating Procedures-Policy Patient Right and Responsibilities

Creighton Health Sciences School Policy_ Patient Rights and Responsibilities

TennDent Policy HIPAA Access Control

University of Tennessee Health Science Center: Access to Protected Health Information

Illinois Administrative Code Joint Committee on Administrative Rules Part 250 Hospital Licensing Requirements

HCA Policy - Query Documentation for Clinical Documentation Improvement (CDI) & Coding - Compliance Requirements

UCSD Health Sciences Compliance/Privacy Program “Comparison of HIPAA’s 18 Protected Health Information (PHI) vs. Limited Data Set (LDS)

University of California - Legal Medical Record Standards Policy

Federal Register - Security and Electronic Signature Standards

Federal Register- Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Order; Securing Medications; and Post anesthesia Evaluations

AHIMA Online Research Journal Perspectives in HIM: “Storage Media Profiles and Health Record Retention Practice Patterns in Acute Care Hospitals”, by Laurie A. Rinehart-Thompson

AHIMA Practice Briefs and Papers Electronic Signature, Attestation, and Authorship

Clinical Documentation Toolkit (AHIMA Body of Knowledge)