Types and Content of Health Records
The graduate evaluates health record types and content for compliance with records storage policies.
Introduction
A health record is a form of communication between internal and external stakeholders in a healthcare environment. Health information management professionals are responsible for managing health records whether in paper, electronic, or hybrid format. Guidelines must be followed in maintaining records, including their storage and destruction, and policies must be evaluated for their compliance with state and federal regulations.
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. The similarity report that is provided when you submit your task can be used as a guide. 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. Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc., unless specified in the task requirements. All other submissions must be file types that are uploaded and submitted as attachments (e.g., .docx, .pdf, .ppt).
A. Compare the characteristics of paper, hybrid, and fully electronic health records.
1. Discuss issues that may affect the use of hybrid records for legal purposes.
Note: Your comparison of the three record types must address storage, accessibility, and how information is amended.
B. Evaluate the attached “Cedar Bend Record Policy” to determine if the policy protects health information for record storage and destruction of paper and electronic health records by doing the following:
1. Describe whether the Cedar Bend record policy would comply with a chosen state’s regulations, including your reasoning. Identify a specific state in your response.
Note: Refer to the attached “Retention and Destruction of Health Information” supporting document to identify your chosen state’s regulations.
2. Describe whether the Cedar Bend record policy for retention would comply with the Medicare Conditions of Participation.
Note: Refer to the attached “Retention and Destruction of Health Information” supporting document for a summary of the Medicare Conditions of Participation.
C. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
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