Task 4 in C803 V

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Western Governors University *

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C803

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Health Science

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May 3, 2024

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C803 Task Notes, V.2. Task 4 Scenario: As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer 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 history and physical assessments are documented in the hospital . There are concerns that stakeholders have ideas of how the new EHR system should function with regard to history and physical documentation, but that there is a lack of understanding as to the applicable regulatory requirements. The purpose of the meeting is to make sure the policy and procedure that address history and physical documentation are both current with regard to The Joint Commission (TJC) and state requirements. Requirements: Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. Use the Turnitin Originality Report available in Taskstream as a guide for this measure of originality. You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course. A. Create a multimedia presentation (e.g., PowerPoint, Keynote) (suggested length of 8–16 slides) for your HIM director and chief medical officer (CMO) to summarize your analysis of history and physical (H&P) documentation compliance. Include presenter notes for each slide (suggested length of 1–2 paragraphs of notes per slide) . Note: Please base your analysis of state regulations on the current state in which you live . or your choice of state – just be consistent throughout . For information on record storage and destruction see HIM text Chapter 4 starting on pp. 99. A. 1. Include a title slide that presents your name and the state in which you reside (or you choose).
A. 2. Include a slide with a table that lists the similarities between The Joint Commission (TJC) standards and your chosen state’s regulations regarding history and physical (H&P) documentation requirements. A. 3. Include a slide with a table that shows the differences between The Joint Commission standards and your chosen state’s regulations regarding how history and physical (H&P) are documented. ***If your selected state’s law does not provide this information, please feel free to use a different state. Please be sure to document the state in the presenter notes and show that state on the title slide and for all other comparisons*** A. 4. Include at least one slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the EHR. ***If your selected state’s law does not provide this information, please feel free to use a different state. Please be sure to document the state in the presenter notes and show that state on the title slide and for all other comparisons*** A. 5. Include at least one slide that shows The Joint Commission standards’ required time frames to complete the history and physical (H&P) documentation with regard to standard medical admissions, readmissions, and surgical admissions. A. 6. Include at least one slide that shows the importance of documenting the patient’s chief complaint as part of the medical history. A. 7. Include at least one slide that shows a list of recommendations for technical improvements for your EHR system to comply with both sets of standards. (Important to go back to scenario for basis on this slide). A. 8 Include at least one slide describing how your organization can monitor and stay current with national and state regulations. (Important to go back to scenario for basis on this slide). B. Acknowledge sources, using APA-formatted 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. (The Joint Commission, 2021) (Electronic Code of Federal Regulations, 2021) (Watters, 2020)
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