Policy on Documentation Requirements in the Health Record – History and Physical Example

Health care organization must have in place policies on the documentation requirements for the entire health record. HIM professionals are responsible for ensuring that the requirements are followed so that the healthcare facility is in compliance with the state and federal laws, accreditation and the Medicare Conditions of Participation (CoP). One vital piece of clinical data in the medical record is the history and physical report. It is imperative that the healthcare facility establishes and follows documentation and completion guidelines for the H&P. For this portion of the policy manual you are required to assess the Documentation Requirements for a health information documentation policy with a focus on the history and physical portion of the policy as an example. Developing the policy that relates to the documentation in a history and physical will allow you to evaluate the requirements of the policy that would encompass the entire record.

Select policies, procedures and guidelines provided for benchmarking in Module 01 under Benchmarking Resources based on appropriateness to this topic, or you may research policies, guidelines and standards on your own to use as a benchmark. Review your selected policies, procedures and guidelines and select the information after comparing those resources that you will include in your policy and write your policy on documentation requirements in the history and physical. Note that the some of the benchmarking policies provided do cover the documentation requirements for the entire record, as an example.

The completed typed policy should be 1 page. If you use a source for the policy, state the source at the end of the policy under a heading titled references.

Overview-Benchmarking Resources

Benchmarking against other organizations polices and/or available guidelines is an important step in the process of developing or revising polices and guidelines for a healthcare organization. Below is a list of benchmarking resources links to policies and guidelines and standards which relate to the topics you will be preparing policies for during the course project. You may select from the list for sources you would use to benchmark in each module and cite those that you use as a reference at the end of your policy or you may research policies, guidelines and standards on your own to use as a benchmark.

Banner Health “Documentation Requirements for the Medical Record-Policy and Procedure

Pennsylvania Hospital & Surgery Center Administrative Policy Manual – Medical Record Documentation Practices

Kansas County Health Department- Medical Records Policy

Joint Commission – “Do Not Use” List

UTMB Policy Manual

UTMB Health Procedure – Prohibited Abbreviations

UTMB Handbook of Operating Procedures-Policy Patient Right and Responsibilities

Creighton Health Sciences School Policy_ Patient Rights and Responsibilities

TennDent Policy HIPAA Access Control

University of Tennessee Health Science Center: Access to Protected Health Information

Illinois Administrative Code Joint Committee on Administrative Rules Part 250 Hospital Licensing Requirements

HCA Policy – Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance Requirements

UCSD Health Sciences Compliance/Privacy Program “Comparison of HIPAA’s 18 Protected Health Information (PHI) vs. Limited Data Set (LDS)

University of California – Legal Medical Record Standards Policy

Federal Register – Security and Electronic Signature Standards

Federal Register- Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Order; Securing Medications; and Post anesthesia Evaluations

AHIMA Online Research Journal Perspectives in HIM: “Storage Media Profiles and Health Record Retention Practice Patterns in Acute Care Hospitals”, by Laurie A. Rinehart-Thompson

AHIMA Practice Briefs and Papers Electronic Signature, Attestation, and Authorship

Clinical Documentation Toolkit (AHIMA Body of Knowledge)

An additional source to perform you own external review of policies, procedures, guidelines and standards is through:

Textbook: Health Information Management Concept, Principles and Practice – Appendix D Web Resource

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