Class: Health Data Management

Assignment: Policy on Documentation Requirements in the Health Record – History and Physical Example

Note: This is a Work Policy and Procedure not a paper.

Health care organization must have in place policies on the documentation requirements for the entire health record. HIM professionals are responsible for ensuring that the requirements are followed so that the healthcare facility is in compliance with the state and federal laws, accreditation and the Medicare Conditions of Participation (CoP). One vital piece of clinical data in the medical record is the history and physical report. It is imperative that the healthcare facility establishes and follows documentation and completion guidelines for the H&P. For this portion of the policy manual you are required to assess the Documentation Requirements for a health information documentation policy with a focus on the history and physical portion of the policy as an example. Developing the policy that relates to the documentation in a history and physical will allow you to evaluate the requirements of the policy that would encompass the entire record.

Benchmarking in Module 01 under Benchmarking Resources based on appropriateness to this topic:

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

If the above link will not open by clicking on it, please copy & paste to the hyperlink below into web browser to open.

Select policies, procedures and guidelines provided for benchmarking in Module 01 under Benchmarking Resources based on appropriateness to this topic, or you may research policies, guidelines and standards on your own to use as a benchmark. Review your selected policies, procedures and guidelines and select the information after comparing those resources that you will include in your policy and write your policy on documentation requirements in the history and physical. Note that the some of the benchmarking policies provided do cover the documentation requirements for the entire record, as an example.

The completed typed policy should be 1-3 pages. If you use a source for the policy, state the source at the end of the policy under a heading titled references in APA Format with In-Text citations.

Save your assignment as a Microsoft Word document.

TIP: Welcome to Week 9! This week we are continuing to write our policies! The policy for this week focuses on documentation in the health record for the History & Physical. By now, you all know how to research this information and include information within your own policy based on what you have researched. However, you may want to utilize some Medicare standards for this policy.

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