You have been asked by your supervisor to write a policy for health record documentation requirements. The policy needs to address the content of the reports, any time, and frequency requirements.
Be sure to review the articles below:
- Practice Brief – Fundamentals of the Legal Health Record and Designated Record Set http://library.ahima.org/doc?oid=104008#.WY8uPFWGO…
- This practice brief compiles and updates information to provide an overview of the purposes of the designated record set, the legal health record, and helps organizations identify what information to include in each. It also provides guidelines for disclosing health records from the sets.
Complete the following.
Policy Template and Documentation Requirements have been attached and for Practice brief please follow the AHIMA website link
You must include rules on each of the following:
- Components and timely completion of the Medical History and Physical Examination
- Components and timely completion of the Operative Report
- Components and timely completion of the Discharge Summary
- When a Final Progress Note can be used instead of a Discharge Summary
- When a Pathology Report must be present
- How often Progress Notes must be recorded
- What should be included, at a minimum, in Progress Notes
- How errors in documentation must be corrected