{"id":19831,"date":"2020-12-08T10:59:01","date_gmt":"2020-12-08T10:59:01","guid":{"rendered":"http:\/\/onlineclassesguru.com\/?p=19831"},"modified":"2020-12-08T10:59:01","modified_gmt":"2020-12-08T10:59:01","slug":"health-record-such-as-the-history-physical-operative-notes-nurses-notes-and-physician-orders-etc","status":"publish","type":"post","link":"https:\/\/onlineclassesguru.com\/index.php\/2020\/12\/08\/health-record-such-as-the-history-physical-operative-notes-nurses-notes-and-physician-orders-etc\/","title":{"rendered":"Health Record such as the History &#038; Physical, Operative Notes, Nurses Notes and Physician Orders etc.)"},"content":{"rendered":"<style type=\"text\/css\"><\/style><h4>Health Record such as the History &amp; Physical, Operative Notes, Nurses Notes and Physician Orders etc.)<\/h4>\n<p>Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much-needed policies to govern the practice of health record documentation within your organization. You must devise two (2) of these policies, adhering to the format listed below and using APA formatting with sub-headings. Submit one (1) single Microsoft Word document.<\/p>\n<p>Deliverables: Create two (2) policies to address electronic health record documentation. You must select from the following list of topics:<\/p>\n<p>The Use of Electronic signatures\/Authentication<br \/>\nLegibility<br \/>\nElectronic Health Record Duplication<br \/>\nHealth Record Amendments<br \/>\nThe Completion of Health Records (adhering to TJC timeline)\u2026including various forms (components within the Health Record such as the History &amp; Physical, Operative Notes, Nurses Notes and Physician Orders etc.)<br \/>\nVerbal &amp; Telephone Orders<br \/>\nThe use of departmental\/organizational wide abbreviations<br \/>\nThe Physician Query Process<br \/>\nThe Use of MACRA &amp; Meaningful Use (MU) Audits<br \/>\nAuthorized Users, including Training &amp; Education and Password Protection and Updates<br \/>\nCopy &amp; Paste Functionality<br \/>\nCloned Documentation<br \/>\nTemplates\/Screen Designs<\/p>\n<p>Health Record Policy Format:<\/p>\n<p>Subject<br \/>\nPurpose<br \/>\nStaff<br \/>\nEffective Date<br \/>\nA thorough description of the policy<br \/>\nDefinition of Terms (associated with policy)<br \/>\nProcedure<br \/>\nConsequences for Failure to Comply<\/p>\n<p>Resources:<\/p>\n<p>Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update): http:\/\/library.ahima.org\/doc?oid=300257#.WHkS_lVpHIV<\/p>\n<p>Fundamentals of the Legal Health Record and Designated Record Set: http:\/\/library.ahima.org\/doc?oid=104008#.WHkTVFVpHIU<\/p>\n<p>Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: http:\/\/www.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Vol-20-2015\/No2-May-2015\/Articles-Previous-Topics\/Technology-Safety-and-Professional-Care-Documentation.html<\/p>\n<p>MACRA &amp; MU: http:\/\/www.fiercehealthcare.com<\/p>\n<p>Sample Compliance Checklists for Electronic Health Records: https:\/\/www.cms.gov\/Medicare-Medicaid-Coordination\/Fraud-Prevention\/Medicaid-Integrity-Education\/Downloads\/ehr-compliance-checklist.pdf<\/p>\n<p>World Health Organization<\/p>\n<p><center><a href=\"http:\/\/onlineclassesguru.com\/orders\/ordernow\"><img decoding=\"async\" src=\"https:\/\/encrypted-tbn0.gstatic.com\/images?q=tbn:ANd9GcTyj99p60XCLyLk1htB7-1neRt8-2QdnenNlQ&usqp=CAU\"target=\"_http:\/\/onlineclassesguru.com\/orders\/ordernow\"\/><\/center><p>","protected":false},"excerpt":{"rendered":"<p>Health Record such as the History &amp; Physical, Operative Notes, Nurses Notes and Physician Orders etc.) Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much-needed policies to govern the practice of health record documentation within your organization. You must devise two (2) of these&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-19831","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Health Record such as the History &amp; Physical, Operative Notes, Nurses Notes and Physician Orders etc.) - onlineclassesguru<\/title>\n<meta name=\"description\" content=\"Health Record such as the History &amp; Physical, Operative Notes, Nurses Notes and Physician Orders etc.)\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"http:\/\/onlineclassesguru.com\/index.php\/2020\/12\/08\/health-record-such-as-the-history-physical-operative-notes-nurses-notes-and-physician-orders-etc\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Health Record such as the History &amp; 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