You have been asked by your supervisor to write a policy for healthrecord documentation requirements. The policy needs to address thecontent of the reports, any time, and frequency requirements.

Be sure to review the articles below from your assigned reading.

• AHIMA Practice Brief – Documentation Requirements for the Acute Care Inpatient Record

To obtain the required articles click on the following link:
http://guides.rasmussen.edu/healthsciences/hithim/courses

• Practice Brief – Fundamentals of the Legal Health Record and Designated Record Set
  • This practice brief compiles and updates information to providean overview of the purposes of the designated record set, the legalhealth record, and helps organizations identify what information toinclude in each. It also provides guidelines for disclosing healthrecords from the sets.

Complete the following.

Policy Template

You must include rules on each of the following:

1. Components and timely completion of the Medical History and Physical Examination
2. Components and timely completion of the Operative Report
3. Components and timely completion of the Discharge Summary
4. When a Final Progress Note can be used instead of a Discharge Summary
5. When a Pathology Report must be present
6. How often Progress Notes must be recorded
7. What should be included, at a minimum, in Progress Notes
8. How errors in documentation must be corrected