Instructions

Imagine that you are an administrator for a large hospital. You have been tasked with compliance for the facility. Demonstrate competence in healthcare law and ethics by following the instructions below in completion of this multi-part assignment.

Part 1

Instructions

Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status.

A 45-year-old female has requested a copy of her 80-year-old father’s health record. She has presented POA and has a legal right to access his records. You provide a copy to the woman, but she has many questions regarding documentation of her father’s diagnosis. He was admitted to the ICU last week from the skilled nursing facility. When discharged, he was transferred to an LTACH. In a brief written response to the woman, relate the components of the health record that supports diagnosis and reflects the patient’s progress, clinical findings, and discharge status. Explain the documentation used for these purposes within skilled nursing facilities, ICU, and LTACH.

Part 2

Identify laws and regulations applicable to health care.

Imagine that you are the Director of Health Information at a hospital and you have been asked to create a “one-page” pamphlet on the major laws and regulations guiding health record retention and destruction. Draft an outline summarizing a total of five (5) best practices in a retention/destruction program. In addition to your text, you may refer to The Joint Commission (TJC), State law(s) (pick any state), and Centers for Medicare and Medicaid Services (CMS).