health record documentation requirements

A policy for health record documentation requirements



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 from your assigned reading.

AHIMA. “Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2014 update)” Journal of AHIMA 84, no.6 (December 2014): 56-61 [expanded web version, updated December 2014 with new implementation date].
Practice Brief – Fundamentals of the Legal Health Record and Designated Record SetThis practice brief compiles and updates the 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.