As the chart completion supervisor for Cedar Bend Hospital, you have an upcoming meeting with the HIM director and the chief medical officer (CMO) 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 H&P assessments are documented in the hospital. There are concerns that stakeholders lack understanding of how the new EHR system should function with regard to H&P documentation and the applicable regulatory requirements. The purpose of the meeting is to make sure Cedar Bend’s policies and procedures that address H&P documentation are current with regard to The Joint Commission (TJC) and state requirements.
What needs to be fixed :
-The presentation gives the correct Joint Comission standards to complete H&P documentation concerning standard and surgical admission. The response related to the Joint Commission’s standards for readmissions is incorrect.
Note: Base your analysis of state regulations on the NEVADA. If Nevada does not have specific regulations, you may choose another state that does.
-The presentation provides a slide with reference. However, there are no in-text citations related to each reference. For specific instruction on in-text and reference list citations, please click on the link located in the rubric items “Sources.”
1. Include a title slide that includes the state you have chosen to base your analysis on.
2. Include a slide with a table that compares the similarities between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).
3. Include a slide with a table that compares the differences between TJC standards and your chosen state’s regulations regarding H&P documentation requirements, including presenter notes (suggested length of 1–2 paragraphs).
4. Include a slide that justifies to your HIM director and CMO the importance of including social and personal history documentation in the H&P, including presenter notes (suggested length of 1–2 paragraphs).
5. Include a slide that describes TJC standards time frames to complete the H&P documentation with regard to standard admissions, surgical admissions, or readmissions, including presenter notes (suggested length of 1–2 paragraphs).
6. Include a slide that shows the importance of documenting the patient’s chief complaint as part of the medical history, including presenter notes (suggested length of 1–2 paragraphs).
7. Include a slide that shows a list of recommendations for your EHR system to comply with both sets of standards for H&P documentation, including presenter notes (suggested length of 1–2 paragraphs).
8. Include a slide describing a plan for how your organization can monitor and stay current with national and state regulations, including presenter notes (suggested length of 1–2 paragraphs).
