Assignment Objectives:
- Meet CAHIIM curriculum requirement for Associate Degree
- Domain I. Data Content Structure and Standards
- Subdomain B. Health Record Content and Documentation
- Section 1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status
- Competencies - Health information media o Paper, computer, web-based document imaging
- Meet CAHIIM curriculum requirement for Bachelor Degree
- Domain I. Data Content Structure and Standards
- Subdomain I.B. Health Record Content and Documentation
- 1. Verify that documentation in the health record supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status
- Competencies - Health record components o General requirements for documentation for all record types
Assignment Purpose:
It is important for Health Information Management professionals to be able to discriminate between a paper record, an EMR and an EHR to apply the appropriate requirements to each format.
Assignment Requirements:
Part One:
Review APA formatting guidelines which can found in the Herzing University Online Library
Part Two:
Locate at least three articles relating to the format and/or content of paper records, electronic medical records and electronic health records.
Part Three:
Create a 2-3 page APA style paper which compares and contrasts at least five different features of a paper health record, an EMR, and an EHR.
Part Four:
Develop two organizational documentation guidelines for a paper health record, an EMR, and an EHR. (Create two guidelines for each type of record - a total of six documentation guidelines). Address web-based document imaging in at least two guidelines.
Sample Guideline: In the paper record, black or blue ink must be used at all times.
Sample Guideline: All progress notes documented in the EHR must contain date, time, and physician authorization.
Be sure to include appropriate in-text citations and references. You should use a minimum of three peer reviewed references. Title page and Reference page does NOT count towards the 2 to 3 page requirement.