Subdomain I.B. Health Record Content and Documentation

Assignment Objectives:

1. Meet CAHIIM curriculum requirement for Associate Degree
   1. Domain I. Data Content Structure and Standards
   2. Subdomain B. Health Record Content and Documentation
   3. 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
   4. Competencies – Health information media o Paper, computer, web-based document imaging
2. Meet CAHIIM curriculum requirement for Bachelor Degree
   1. Domain I. Data Content Structure and Standards
   2. Subdomain I.B. Health Record Content and Documentation
   3. 1. Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status
   4. 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.