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As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming
As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer (CMO) regarding history and physical (H&P) documentation compliance. Cedar Bend is doing a system update of its electronic health record (EHR), and there are new design capabilities with regard to how H&P assessments are documented in the hospital. There are concerns that stakeholders lack understanding of how the new EHR system should function with regard to H&P documentation and the applicable regulatory requirements. The purpose of the meeting is to make sure Cedar Bend’s policies and procedures that address H&P documentation are current with regard to The Joint Commission (TJC) and state requirements.
Include a slide with a table that compares the similarities between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).
3. Include a slide with a table that compares the differences between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).
4. Include a slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the H&P, including presenter notes (suggested length of 1–2 paragraphs).
5. Include a slide that describes TJC standards time frames to complete the H&P documentation with regard to standard admissions, surgical admissions, or readmissions, including presenter notes (suggested length of 1–2 paragraphs).
6. Include a slide that shows the importance of documenting the patient’s chief complaint as part of the medical history, including presenter notes (suggested length of 1–2 paragraphs).
7. Include a slide that shows a list of recommendations for your EHR system to comply with both sets of standards for H&P documentation, including presenter notes (suggested length of 1–2 paragraphs).
8. Include a slide describing a plan for how your organization can monitor and stay current with national and state regulations, including presenter notes (suggested length of 1–2 paragraphs).
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
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