The Medical Record Documentation Case Study Essay Solution

 The Medical Record Documentation Case Study Essay

Table of Contents

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Instructions

 The Medical Record Documentation Case Study Essay

As a new HIM professional, you have been given the task of updating the medical record documentation requirements, taking into consideration your state, Centers for Medicare and Medicaid Services (CMS), and Joint Commission requirements. As the first step in this process, your manager has requested the following:

Identify whether your state has a medical-legal manual prepared by the state Health Information Management Association.

If so, identify the cost of the manual and the section of the Table of Contents that addresses the content of the legal health record.

List the following items using the Week 2 Assignment Template other comparison format:

The Medical Record Documentation Case Study Essay

Review your state statutes, rules, and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.

Review your CMS rules and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.

Using the University of Arizona Global Campus Library, access the Joint Commission Accreditation and Certification Manual and identify all standard sections for any reference to the health record content and documentation, authentication as well as completion requirements.

The Medical Record Documentation Case Study

The Medical Record Documentation Case Study Essay

RUBRIC
Excellent Quality 95-100%	Introduction 45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.		Literature Support 91-84  points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.			Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score 50-85%	40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.		83-76  points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.			52-49  points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality 0-45%	37-1 points The background and/or significance are missing. No search history information is provided.		75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.			48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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