Explain best documentation practices pertaining to health record (i.e. documentation errors) in an EHR (Electronic Health Record) format.

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Explain best documentation practices pertaining to health record (i.e. documentation errors) in an EHR (Electronic Health Record) format.

Documentation Standards

You are going to pretend you work in the HIM department at a NON-ACUTE healthcare setting of your choice. (i.e. home health, physician office, long term care, hospice, rehabilitation, corrections, ESRD, anything non-acute, etc.)

A new provider has just been hired and this provider has not worked in this type of setting before.

You have been given the task to educate this provider on documentation standards at your facility.

Create a presentation that you will use to assist you while educating the provider. This will be done as a power point presentation.

Information To Include:

Required documentation, in the health record, from the time they are being cared for to when the care is done. (i.e. H&P (history and physical), nursing type assessments (if applicable) etc).

Assign an accreditation agency to your facility and explain their specific documentation in the health record. (i.e. Joint commission. AAAHC, etc.)

Explain best documentation practices pertaining to health record (i.e. documentation errors) in an EHR (Electronic Health Record) format.

Explain the timeframe requirements for verbal orders and any other assessments necessary for patient care. (i.e. H&P, pharmacist documentation review, physician visit frequencies, etc)

If your facility accepts medicare/medicaid patients make sure to explain CMS (www.cms.gov) documentation guidelines.

Since the doctor is responsible for the care of the patient, it is important they understand the other disciplinarians that may also care for the patient (i.e. nurses, PT/OT, etc.). Make sure you include these if it is applicable to your healthcare setting.

The information you collect will depend on the healthcare setting you choose, so don’t think that the examples I provided are ones you have to use. For example, a physician office would not have nursing assessments like you would find in long term care settings. Think of the documentation that is specific for the healthcare setting. Think about the movement of that patient in that healthcare setting. Think about the different accreditation agencies based on the healthcare setting. Perhaps the one you chose doesn’t have one, so you would want to make sure to document that.

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