ASSIGNMENT: Create Health Information
CAHIIM Competency: Subdomain I.B. Health
Record Content and Documentation
organization-wide health record documentation guidelines
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outdated and it appears they have not been updated for nearly 10 years.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.
the documentation standards for the Joint Commission and CMS and Conditions
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.
the document as a policy and write a short explanation of the purpose of
the document and how it should be used.