.<\/p>\n

.<\/p>\n

SPC Real World Case 4.2: Anywhere Hospital Copy Paste Function<\/p>\n

<\/p>\n

Real World Case 4.220 POINTS<\/strong><\/h2>\n

For this activity, you will review the\u00a0Real World Case 4.2<\/strong>\u00a0in your textbook. Conduct an analysis of the situation and summarize how you would have addressed the issues by answering the questions below.<\/p>\n

Analyze\u00a0Real World Case 4.2<\/strong>. Read the case study and then answer the following questions.<\/p>\n

What should be considered when deciding whether or not to use the copy and paste functionality?<\/p>\n

What controls might be put in place related to the copy and paste functionality?<\/p>\n

What alternatives to the copy and paste functionality are available?<\/p>\n

Health Information Management Technology: An Applied Approach Sixth Edition Chapter 4: Health Record Content and Documentation ahima.org ahima.org \u00a9 2020 AHIMA \u00a9 2019 \u00a9 2020 American Health Information Management Association Documentation \u2022 Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers \u2022 Allows for the telling and retelling of events ahima.org \u00a9 2020 AHIMA \u00a9 2019 Impact of Poor Documentation \u2022 Poor outcomes \u2022 Issues with patient care \u2022 Issues with the accuracy of diagnosis and procedure codes \u2022 Errors on healthcare claim ahima.org \u00a9 2020 AHIMA \u00a9 2019 Documentation Standards \u2022 Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation. \u2022 Dictates how healthcare providers should document the treatment and services within the health record. ahima.org \u00a9 2020 AHIMA \u00a9 2019 Standard Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals. ahima.org \u00a9 2020 AHIMA \u00a9 2019 Documentation Standard \u2022 Standard that controls health record documentation ahima.org \u00a9 2020 AHIMA \u00a9 2019 Documentation Standards and E H R s \u2022 E H R s and paper-based health records typically have the same basic documentation standards \u2022 Templates ahima.org \u00a9 2020 AHIMA \u00a9 2019 Standards 1 Documentation standards have grown in complexity and detail over time Focus on \u2022 Patient care quality \u2022 Appropriate reimbursement \u2022 Prevention of fraud and abuse ahima.org \u00a9 2020 AHIMA \u00a9 2019 Standards 2 Documentation standards vary upon the type of health record Multiple sources of documentation standards: \u2022 Insurance company or payers \u2022 Government regulatory agencies \u2022 Licensing boards \u2022 Accrediting bodies \u2022 Facility policies and procedures \u2022 Medical staff bylaws ahima.org \u00a9 2020 AHIMA \u00a9 2019 Goals of Documentation Standards \u2022 Ensure complete health record and accurately reflects the treatment provided to the patient \u2022 Drive appropriate reimbursement through accurate code capture ahima.org \u00a9 2020 AHIMA \u00a9 2019 Medical Staff Bylaws 1 \u2022 Standards governing the practice of medical staff members \u2022 Voted on by the organized medical staff and the medical staff executive committee \u2022 Approved by the healthcare organization\u2019s board of directors \u2022 Used to enforce quality of care ahima.org \u00a9 2020 AHIMA \u00a9 2019 Medical Staff Bylaws 2 Required by \u2022 Licensure organizations \u2022 Accreditation organization \u2022 Federal and state regulatory agencies Each organization mandates content Medical staff bylaws will vary slightly from one organization to another ahima.org \u00a9 2020 AHIMA \u00a9 2019 Medical Staff \u2022 Physicians and nonphysician providers who have privileges to practice medicine at a particular healthcare organization \u2022 May or may not be employed by the healthcare organization \u2022 Medical staff are subject to the medical staff bylaws ahima.org \u00a9 2020 AHIMA \u00a9 2019 Medical Staff Privileges Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization ahima.org \u00a9 2020 AHIMA \u00a9 2019 Accreditation 1 \u2022 A voluntary process \u2022 Periodical evaluation against preestablished written criteria \u2022 Healthcare organizations measure their own compliance with standards \u2022 Enhances the reputation of the organization in the eyes of the patient \u2022 Differs by the type of program or service ahima.org \u00a9 2020 AHIMA \u00a9 2019 Accreditation 2 Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies ahima.org \u00a9 2020 AHIMA \u00a9 2019 Accreditation Organization Must go through its own CMS review to obtain deemed status \u2022 Evaluates healthcare organizations for compliance with C o P s and CFCs ahima.org \u00a9 2020 AHIMA \u00a9 2019 Joint Commission 1 \u2022 Accredits wide variety of healthcare organizations \u2022 Continuously updates survey processes \u2022 Surveys clinical and operational components \u2022 Provides education to healthcare organizations related to compliance ahima.org \u00a9 2020 AHIMA \u00a9 2019 Joint Commission 2 Provides accreditation for: \u2022 Ambulatory healthcare \u2022 Behavioral health \u2022 Critical access hospital \u2022 Homecare \u2022 Hospital ahima.org \u00a9 2020 AHIMA \u00a9 2019 \u2022 Laboratory \u2022 Nursing care centers \u2022 Physician offices \u2022 Office-based surgery centers Other Accreditation Organizations \u2022 Healthcare Facilities Accreditation Program \u2022 Commission on Accreditation of Rehabilitation Facilities \u2022 Accreditation Association for Ambulatory Healthcare ahima.org \u00a9 2020 AHIMA \u00a9 2019 State Statutes \u2022 Legislation written and approved by a state legislature and then signed into law by the state\u2019s governor \u2022 Addresses the documentation requirements for specific types of health records ahima.org \u00a9 2020 AHIMA \u00a9 2019 Legal Health Record 1 Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information \u2022 Content varies from provider organization to another ahima.org \u00a9 2020 AHIMA \u00a9 2019 Legal Health Record 2 Policies and procedures should be established to defining legal health record ahima.org \u00a9 2020 AHIMA \u00a9 2019 General Documentation Guidelines 1 \u2022 Apply to all categories of health records \u2022 Every healthcare organization should have policies \u2022 Organized systematically to facilitate data retrieval and compilation ahima.org \u00a9 2020 AHIMA \u00a9 2019 General Documentation Guidelines 2 \u2022 Only individuals authorized by the organization\u2019s policies should be allowed to enter documentation in the health record. \u2022 Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician\u2019s orders. ahima.org \u00a9 2020 AHIMA \u00a9 2019 General Documentation Guidelines 3 \u2022 Health record entries should be documented at the time the services they describe are rendered. \u2022 Authors of entries should be clearly identified in the record. \u2022 Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record. ahima.org \u00a9 2020 AHIMA \u00a9 2019 General Documentation Guidelines 4 All entries in the health record should be permanent. Any corrections or information added to the record by the patient should be inserted as an addendum \u2022 No changes should be made in the original entries in the record \u2022 Information added to the health record by the patient should be clearly identified as an addendum ahima.org \u00a9 2020 AHIMA \u00a9 2019 CMS Documentation Requirements Entries must be \u2022 Legible \u2022 Complete \u2022 Dated and timed \u2022 Author identified \u2022 Authenticated in written or electronic form ahima.org \u00a9 2020 AHIMA \u00a9 2019 Authentication Identifying the source of health record entries \u2022 Written signature \u2022 Initials \u2022 Electronic signature CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated ahima.org \u00a9 2020 AHIMA \u00a9 2019 Auto-Authentication When a physician or other care provider authenticates an entry without reviewing ahima.org \u00a9 2020 AHIMA \u00a9 2019 Documentation by Setting 1 Health record information consists of two types regardless of setting \u2022 Clinical \u2022 Administrative ahima.org \u00a9 2020 AHIMA \u00a9 2019 Documentation by Setting 2 \u2022 Must have health record for each person \u2022 Content varies by setting \u2022 Contains clinical and administrative data ahima.org \u00a9 2020 AHIMA \u00a9 2019 Inpatient Health Record \u2022 Patient stays overnight \u2022 Medical or surgical \u2022 Most complex health record ahima.org \u00a9 2020 AHIMA \u00a9 2019 Inpatient Health Record\u2014Clinical Medical history \u2022 Current condition \u2022 Past medical history \u2022 Personal history \u2022 Family history \u2022 Chief complaint ahima.org \u00a9 2020 AHIMA \u00a9 2019 1 Inpatient Health Record\u2014Clinical 2 Physical exam \u2022 Physician assessment Diagnostic and therapeutic procedure order \u2022 Physician order \u2022 Standing order ahima.org \u00a9 2020 AHIMA \u00a9 2019 Inpatient Health Record\u2014Clinical Clinical observation \u2022 Progress note \u2022 Integrated health record \u2022 Summary statement (death) Care plan ahima.org \u00a9 2020 AHIMA \u00a9 2019 3 Inpatient Health Record\u2014Clinical 4 Autopsy report Vital signs Flow charts Diagnostic and therapeutic procedure reports \u2022 Lab, pathology, and radiology and other tests\/treatments ahima.org \u00a9 2020 AHIMA \u00a9 2019 Inpatient Health Record\u2014Clinical \u2022 Anesthesia report \u2022 Operative report \u2022 Recover room report \u2022 Pathology report \u2022 Consultation report ahima.org \u00a9 2020 AHIMA \u00a9 2019 5 Inpatient Health Record\u2014Clinical 6 Discharge summary \u2022 Overview of encounter \u2022 Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn Patient instructions Transfer records ahima.org \u00a9 2020 AHIMA \u00a9 2019 Inpatient Health Record\u2014Administrative Patient registration \u2022 Demographics ahima.org \u00a9 2020 AHIMA \u00a9 2019 1 Special Health Records Some health records have unique requirements because of the specialized services provided ahima.org \u00a9 2020 AHIMA \u00a9 2019 Obstetric and Newborn Health Record Obstetric \u2022 Prenatal \u2022 Labor and delivery Newborn \u2022 APGAR ahima.org \u00a9 2020 AHIMA \u00a9 2019 Ambulatory Health Record – General \u2022 Demographics \u2022 Problem list ahima.org \u00a9 2020 AHIMA \u00a9 2019 Ambulatory Surgery Record \u2022 Similar to inpatient surgical health record \u2022 Follow-up post surgery ahima.org \u00a9 2020 AHIMA \u00a9 2019 Ancillary Departments Tests and procedures ahima.org \u00a9 2020 AHIMA \u00a9 2019 Physician Office Record \u2022 Preventive care \u2022 Minor illnesses and injuries ahima.org \u00a9 2020 AHIMA \u00a9 2019 Long-Term Care Ongoing assessments Care plan \u2022 Resident Assessment instrument \u2022 Minimum Data Set for Long-Term Care ahima.org \u00a9 2020 AHIMA \u00a9 2019 Rehabilitation Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument \u2022 5-Day Assessment (mandatory) \u2022 Interim Payment Assessment (optional) \u2022 Discharge Assessment (mandatory) ahima.org \u00a9 2020 AHIMA \u00a9 2019 Behavioral Health \u2022 Includes similar content \u2022 Family and caregiver input is documented ahima.org \u00a9 2020 AHIMA \u00a9 2019 Home Health \u2022 Treatment plan \u2022 Health assessment \u2022 Problem list \u2022 Treatment goals \u2022 Interventions and outcomes ahima.org \u00a9 2020 AHIMA \u00a9 2019 Federal and State Initiatives on Documentation Trends are to focus on \u2022 Quality of care provided \u2022 Value-based care Reimbursement provide incentives for quality of care MACRA Core Measures ahima.org \u00a9 2020 AHIMA \u00a9 2019 Paper Health Record\u2014Format Source-oriented health record Universal chart order Integrated health record Problem-orientated medical record \u2022 Subjective, Objective, Assessment, Plan (SOAP) ahima.org \u00a9 2020 AHIMA \u00a9 2019 Electronic Health Record \u2022 Point-of-care documentation \u2022 Documentation captured electronically ahima.org \u00a9 2020 AHIMA \u00a9 2019 Web-Based Document Imaging \u2022 Capture, digitize, integrate, store, and retrieve paper-based health record documentation \u2022 Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation ahima.org \u00a9 2020 AHIMA \u00a9 2019 Role of Healthcare Professionals in Documentation 1 Physicians \u2022 Document appropriately so that quality care can be rendered and that appropriate reimbursement can occur ahima.org \u00a9 2020 AHIMA \u00a9 2019 Role of Healthcare Professionals in Documentation 2 Nurses \u2022 Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures ahima.org \u00a9 2020 AHIMA \u00a9 2019 Role of Healthcare Professionals in Documentation 3 Allied Health Professionals \u2022 Many follow treatment plan developed by the patient\u2019s physician or a therapist or technologist \u2022 Documents treatment and patient\u2019s response ahima.org \u00a9 2020 AHIMA \u00a9 2019 H I M and Documentation \u2022 Plays vital and different roles in the overall governance of health record information \u2022 Manages many aspects of the health record and its content \u2022 Used in coding, billing, and other H I M functions ahima.org \u00a9 2020 AHIMA \u00a9 2019 H I M Roles \u2022 Clinical documentation integrity coordinator \u2022 Analyst ahima.org \u00a9 2020 AHIMA \u00a9 2019<\/p>\n

A Sample Answer For the Assignment: HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study<\/strong><\/h2>\n

Title: <\/strong> HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study<\/strong><\/h2>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study Sample Answer for HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study Included After Question Description Discussion 4.1: Outside Influence on Healthcare Documentation Guidelines Please make sure your discussion posts include all of the items below: Summarize\u00a0what influence\u00a0outside entities have […]<\/p>\n","protected":false},"author":11,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-27609","post","type-post","status-publish","format-standard","hentry","category-nursing-papers"],"blocksy_meta":{"styles_descriptor":{"styles":{"desktop":"","tablet":"","mobile":""},"google_fonts":[],"version":6}},"yoast_head":"\n