Medical Record Documentation Case Study

 

 

Medical Record Documentation Case Study

[WLOs: 3, 4, 5] [CLOs: 2, 3, 4]

Prior to beginning work on this assignment, read Chapters 5 and 9 from the Fundamentals of Law for Health Informatics and Information Management textbook, review the AHIMA Amendments in the Electronic Health Record Toolkit  Download AHIMA Amendments in the Electronic Health Record Toolkitand access the Joint Commission Accreditation and Certification Manual, located in the University of Arizona Global Campus

As a new HIM professional, you have been given the task of updating the medical record documentation requirements, taking into consideration your state, Centers for Medicare and Medicaid Services (CMS), and Joint Commission requirements. As the first step in this process, your manager has requested the following:

• Identify whether your state has a medical-legal manual prepared by the state Health Information Management Association.
  • If so, identify the cost of the manual and the section of the Table of Contents that addresses the content of the legal health record.
• Include the following items in your submission:
  • Review your state statutes, rules, and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.
  • Review your CMS rules and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.
  • Using the University of Arizona Global Campus Library, access the Joint Commission Accreditation and Certification Manual and identify all standard sections for any reference to the health record content and documentation, authentication as well as completion requirements.

The Medical Record Documentation Case Study

• Must be two to three double-spaced paged in length (not including title and references pages) and formatted according to APA Style as outlined in the Writing Center (Links to an external site.)’s APA Style (Links to an external site.) resource.
• Must include a separate title page with the following:
  • Title of paper
  • Similarity score from Turnitin
  • Student’s name
  • Course name and number
  • Instructor’s name
  • Date submitted
• For further assistance with the formatting and the title page, refer to APA Formatting for Word 2013 (Links to an external site.).
• Must utilize academic voice. See the Academic Voice (Links to an external site.) resource for additional guidance.
• Must include an introduction and conclusion paragraph. Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper.
  • For assistance on writing Introductions & Conclusions (Links to an external site.) as well as Writing a Thesis Statement (Links to an external site.), refer to the Writing Center resources.
• Must use at least four scholarly or credible sources in addition to the weekly required reading.
  • The Scholarly, Peer-Reviewed, and Other Credible Sources (Links to an external site.) table offers additional guidance on appropriate source types. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source for a particular assignment.
  • To assist you in completing the research required for this assignment, view this University of Arizona Global Campus Library Quick ‘n’ Dirty (Links to an external site.) tutorial, which introduces the University of Arizona Global Campus Library and the research process, and provides some library search tips.
• Must document any information used from sources in APA Style as outlined in the Writing Center’s APA: Citing Within Your Paper (Links to an external site.) guide.
• Must include a separate reference page that is formatted according to APA Style as outlined in the Writing Center. See the APA: Formatting Your References List (Links to an external site.) resource in the Writing Center for specifications.

Carefully review the Grading Rubric (Links to an external site.) for the criteria that will be used to evaluate your assignment.