ASSIGNMENT: Create Health Information Documentation Guidelines

CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation

·         Compile organization-wide health record documentation guidelines

Scenario: You are the new HIM Director for Community Healthcare which includes an acute care hospital, an attached clinic and an attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines.

You first need to compile the guidelines set forth by Joint Commission and CMS since those are the regulatory bodies that monitor your organization.

Instructions:

1. Locate the documentation standards for the Joint Commission and CMS and Conditions of Participation.
2. Create a table listing medical record documentation standards for both the Joint Commission and CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic, and Longterm Care). You will have 3 tables, one for each type of facility.
3. Title the document as a policy and write a short explanation of the purpose of the document and how it should be used.