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. 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. An additional source to perform you own external review of policies, procedures, guidelines and standards is through: Health Information Management Concept, Principles and Practice – Appendix D Web Resource