Examine the potential components of the legal health record and the challenges associated with their inclusion.

Unit 4 Assignment: Disclosure and Documentation

Unit Outcomes assessed in this assignment:

Discuss liability in health care.
Examine the potential components of the legal health record and the challenges associated with their inclusion.
Differentiate the entities that establish documentation and maintenance standards for the health record.
Create policies that support legally sound documentation principles.
Develop procedures for the identification, retention, and disposition of health records.
Course Outcomes assessed in this assignment:

HI135-2: Illustrate how health care laws and regulations apply to the management of health information.

GEL-1.02: Demonstrate college-level communication through the composition of original materials in Standard English.

BSHIM I.1: Compare diverse stakeholder perspectives through the delivery of health care services.

AAS-HIT: I.4 Determine compliance of health record content within the health organization.

Instructions:

Part 1

A cause of action for improper disclosure of health information may result from either a negligent or an intentional act. Complete an internet search and find news stories related to breach of patient confidentiality. Write a summary of at least one of the stories you find, outlining the elements of a cause of action for negligence outlined in the reading for this unit. Be sure to use your text as a reference for your work. Discuss liability in health care and legal concepts and principles, and use legal terminology from the reading, supporting your opinion about the improper disclosure.

Part 1 writing requirements: Your summary should be approximately 500 words.

Part 2

Visit The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), and Centers for Medicare and Medicaid Services (CMS) websites and spend some time navigating the sites to learn more about these important healthcare regulatory agencies.

The Joint Commission. (2018). Leading the way to zero. www.jointcommission.org

Commission on Accreditation of Rehabilitation Facilities. (2018). CARF accreditation focuses on quality, results. http://www.carf.org/home

Centers for Medicare and Medicaid Services (2018). Regulations & guidance. https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html

Select one of the agencies above and investigate the following questions to prepare for your written assignment:

What is the importance of the agency you selected?
Identify and compare the documentation guidelines for the health record from the agency you selected for at least two different healthcare settings.
What are the ramifications if documentation guidelines are not met for each of the healthcare settings you chose (stakeholders’ perspective)?
How often do facilities undergo surveys?
Written Assignment Requirements:

For your written assignment, you will utilize your research to write an informative essay that reviews the areas outlined in the questions above. The informative essay you create will be used as a job aid for new hires at your facility.
Your informative essay should be a minimum of 500 words, in Microsoft Word format, double-spaced in 12-pt Times New Roman font.
Include a title page and reference page. Be sure to use APA in-text citations in addition to the reference page to attribute each source.
Your writing should follow APA format and follow the conventions of Standard English (correct grammar, punctuation, etc.).
Your writing should be well ordered, logical, and unified, as well as original and insightful.
Your work should display superior content, organization, style, and mechanics.
Rubric:

Unit 4 Assignment Rubric
(the text book – Legal Aspects of Heatlh Information Ch 8-9

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