HEALTH RECORDS DOCUMENTATION AND STORAGE

January 18, 2023

HEALTH RECORDS DOCUMENTATION AND STORAGE

Order Number	653978657654656874
Type of Project	ESSAY/DISERTATION
Writer Level	PHD/MASTERS CERTIFIED
Format	APA/MLA/HARVARD/OXFORD
Academic Sources	10 -20
Page Count	4-8 PAGES

Instructions/Descriptions

HEALTH RECORDS DOCUMENTATION AND STORAGE

As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer (CMO) regarding history and physical (H&P) documentation compliance. Cedar Bend is doing a system update of its electronic health record (EHR), and there are new design capabilities with regard to how H&P assessments are documented in the hospital. There are concerns that stakeholders lack understanding of how the new EHR system should function with regard to H&P documentation and the applicable regulatory requirements. The purpose of the meeting is to make sure Cedar Bend’s policies and procedures that address H&P documentation are current with regard to The Joint Commission (TJC) and state requirements.

Note: Base your analysis of state regulations on the NEVADA. If Nevada does not have specific regulations, you may choose another state that does.

Include a title slide that includes the state you have chosen to base your analysis on.

Include a slide with a table that compares the similarities between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide with a table that compares the differences between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the H&P, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that describes TJC standards time frames to complete the H&P documentation with regard to standard admissions, surgical admissions, or readmissions, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that shows the importance of documenting the patient’s chief complaint as part of the medical history, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide that shows a list of recommendations for your EHR system to comply with both sets of standards for H&P documentation, including presenter notes (suggested length of 1–2 paragraphs).

Include a slide describing a plan for how your organization can monitor and stay current with national and state regulations, including presenter notes (suggested length of 1–2 paragraphs).

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HEALTH RECORDS DOCUMENTATION AND STORAGE

RUBRIC

Excellent Quality

95-100%

Introduction

45-41 points

The context and relevance of the issue, as well as a clear description of the study aim, are presented. The history of searches is discussed.

Literature Support

91-84 points

The context and relevance of the issue, as well as a clear description of the study aim, are presented. The history of searches is discussed.

Methodology

58-53 points

With titles for each slide as well as bulleted sections to group relevant information as required, the content is well-organized. Excellent use of typeface, color, images, effects, and so on to improve readability and presenting content. The minimum length criterion of 10 slides/pages is reached.

Average Score

50-85%

40-38 points

More depth/information is required for the context and importance, otherwise the study detail will be unclear. There is no search history information supplied.

83-76 points

There is a review of important theoretical literature, however there is limited integration of research into problem-related ideas. The review is just partly focused and arranged. There is research that both supports and opposes. A summary of the material given is provided. The conclusion may or may not include a biblical integration.

52-49 points

The content is somewhat ordered, but there is no discernible organization. The use of typeface, color, graphics, effects, and so on may sometimes distract from the presenting substance. It is possible that the length criteria will not be reached.

Poor Quality

0-45%

37-1 points

The context and/or importance are lacking. There is no search history information supplied.

75-1 points

There has been an examination of relevant theoretical literature, but still no research concerning problem-related concepts has been synthesized. The review is just somewhat focused and organized. The provided overview of content does not include any supporting or opposing research. The conclusion has no scriptural references.

48-1 points

There is no logical or apparent organizational structure. There is no discernible logical sequence. The use of typeface, color, graphics, effects, and so on often detracts from the presenting substance. It is possible that the length criteria will not be reached.