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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.
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).
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
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