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:
- 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