HI135-5: Analyze state and federal regulations which govern the release of protected health information.

CAHIM Outcome(s):

Evaluate policies and strategies to achieve data integrity.
Recommend compliance of health record content across the health system.
Assignment Guidelines

Quoting should be less than 10% of the entire paper. Paraphrasing is necessary.
You may cite and reference four (4) credible sources from the Library in addition to the course text and federal and state healthcare policy sites.
Please be sure to download the file Writing Center Resources from Course Resources to assist you with meeting APA expectations for written Assignments.
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

Competency Assessed

Instructions

1

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.

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).

3

Analyze legal concepts and principles to the practice of HIM.

A hacker has penetrated the network of the business associate who provides cloud-based storage for the hospital. All patient records within the last two months were compromised. As HIM Director, you have been tasked with organizing a response to this breach. Differentiate the steps related to breach notification.

4

Evaluate policies and strategies to achieve data integrity.

A patient has requested an amendment to their medical record and the provider does not agree with the amendment language the patient wants. Recommend via policy how you would ensure data integrity and quality of health information exchange.

5

Recommend compliance of health record content across the health system.

Imagine you are the Manager of a Health Information Management Department. The Board of Directors has tasked you with evaluating and interpreting the Joint Commission standards regarding documentation and develop a recommendation on how the facility can ensure compliance with documentation standards.

This Assessment should be a Microsoft Word (minimum 1500 words) document, in addition to the title and reference pages.

Minimum Submission Requirements

Your paper must be written in Standard English and demonstrate exceptional content, organization, style, and grammar and mechanics.
Your writing should be well ordered, logical and unified, as well as original and insightful.
A separate page at the end of your paper should contain a list of references, in APA format. Use your textbook, the Library, and the internet for research.
Be sure to cite both in-text and reference list citations where appropriate and reference all sources. Your sources and content should follow proper APA citation style. Review the APA formatting and citation style found in the Writing Center. The Writing Center can be found within the Academic Support Center under Academic Tools in the left navigation of your course. (It should include a cover sheet, paper is double spaced, in Times New Roman 12-point font, correct citations, Standard English with no spelling or punctuation errors, and correct references at the bottom of the last page.)
If work submitted for this competency assessment does not meet the minimum submission requirements, it will be returned without being scored.