Health Records Compliance

Competencies 730.9.3 : Types and Content of Health Records The learner evaluates health record types and content for compliance with records storage policies. Introduction A health record is a form of communication between internal and external stakeholders in a healthcare environment. Health information management professionals are responsible for managing health records in paper, electronic, or hybrid formats. Guidelines for maintaining records must be followed, including record storage and destruction, and policies must be evaluated for their compliance with state and federal regulations. Requirements Your submission must represent your original work and understanding of the course material. Most performance assessment submissions are automatically scanned through the WGU similarity checker. Students are strongly encouraged to wait for the similarity report to generate after uploading their work and then review it to ensure Academic Integrity guidelines are met before submitting the file for evaluation. See Understanding Similarity Reports for more information. Grammarly Note: Professional Communication will be automatically assessed through Grammarly for Education in most performance assessments before a student submits work for evaluation. Students are strongly encouraged to review the Grammarly for Education feedback prior to submitting work for evaluation, as the overall submission will not pass without this aspect passing. See Use Grammarly for Education Effectively for more information. Microsoft Files Note: Write your paper in Microsoft Word (.doc or .docx) unless another Microsoft product, or pdf, is specified in the task directions. Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc. All supporting documentation, such as screenshots and proof of experience, should be collected in a pdf file and submitted separately from the main file. For more information, please see Computer System and Technology Requirements. You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course. A. Compare the characteristics of paper, electronic, and hybrid health record types by doing the following: 1. Discuss the characteristics of paper health records by addressing their methods of storage, accessibility, and the process for amending information. 2. Discuss the characteristics of electronic health records by addressing their methods of storage, accessibility, and the process for amending information. 3. Discuss the characteristics of hybrid health records by addressing their methods of storage, accessibility, and the process for amending information. a. Discuss issues that may affect the use of hybrid records for legal purposes. B. Evaluate the attached “Cedar Bend Record Policy” and “State A Health Information Retention and Destruction Statute” to determine whether the record policy protects health information for record storage and destruction of paper and electronic health records by doing the following: 1. Describe whether the Cedar Bend record policy is in compliance with State A’s retention policy, including your reasoning. 2. Describe whether the Cedar Bend destruction policy is in compliance with federal guidelines, including your reasoning. Note: Refer to the attached “Federal Policy for Retention and Destruction of Health Information” for more information on federal policy. 3. Describe whether the Cedar Bend record policy for retention would comply with the Medicare Conditions of Participation. Note: Refer to the attached “Retention and Destruction of Health Information” supporting document for a summary of the Medicare Conditions of Participation. C. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. D. Demonstrate professional communication in the content and presentation of your submission. File Restrictions File name may contain only letters, numbers, spaces, and these symbols: ! – _ . * ‘ ( ) File size limit: 200 MB File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, csv, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z Rubric A1:CHARACTERISTICS OF PAPER HEALTH RECORDS Not Evident A submission that discusses the methods of storage, accessibility, and amending information in paper health records is not provided. Approaching Competence The submission does not accurately discuss the methods of storage, accessibility, and amending information in paper health records. Competent The submission accurately discusses the methods of storage, accessibility, and amending information in paper health records. A2:CHARACTERISTICS OF ELECTRONIC HEALTH RECORDS Not Evident A submission that discusses the methods of storage, accessibility, and amending information in electronic health records is not provided. Approaching Competence The submission does not accurately discuss the methods of storage, accessibility, and amending information in electronic health records. Competent The submission accurately discusses the methods of storage, accessibility, and amending information in electronic health records. A3:CHARACTERISTICS OF HYBRID HEALTH RECORDS Not Evident A submission that discusses the methods of storage, accessibility, and amending information in hybrid health records is not provided. Approaching Competence The submission does not accurately discuss the methods of storage, accessibility, and amending information in hybrid health records. Competent The submission accurately discusses the methods of storage, accessibility, and amending information in hybrid health records. A3a:LEGAL ISSUES Not Evident A discussion of issues associated with the use of hybrid records for legal purposes is not provided. Approaching Competence The discussion does not logically explain the issues that could affect the use of hybrid records for legal purposes. Competent The discussion logically explains the issues that could affect the use of hybrid records for legal purposes. B1:STATE RETENTION POLICY Not Evident A description of whether the Cedar Bend record policy complies with State A’s retention policy is not provided. Approaching Competence The description does not accurately address whether the Cedar Bend record policy complies with State A’s retention policy. Or the description does not include appropriate reasoning or does not accurately identify relevant regulations for retention to support whether the Cedar Bend record policy is compliant. Competent The description accurately addresses whether the Cedar Bend record policy complies with State A’s retention policy. The description includes appropriate reasoning and accurately identifies relevant regulations to support whether the Cedar Bend record policy is compliant. B2:FEDERAL GUIDELINES Not Evident A description of whether the Cedar Bend destruction policy complies with federal guidelines is not provided. Approaching Competence The description does not accurately address whether the Cedar Bend destruction policy complies with federal guidelines. Or the description does not include appropriate reasoning or does not accurately identify relevant regulations to support whether the Cedar Bend destruction policy is compliant. Competent The description accurately addresses whether the Cedar Bend destruction policy complies with federal guidelines. The description includes appropriate reasoning and accurately identifies relevant regulations to support whether the Cedar Bend destruction policy is compliant. B3:MEDICARE CONDITIONS OF PARTICIPATION Not Evident A description of whether the Cedar Bend record policy for retention would comply with the Medicare Conditions of Participation is not provided. Approaching Competence The description does not accurately address whether the Cedar Bend record policy for retention would comply with the Medicare Conditions of Participation. Or the description does not provide appropriate examples that support whether the Cedar Bend record policy for retention is compliant. Competent The description accurately addresses whether the Cedar Bend record policy for retention would comply with the Medicare Conditions of Participation. The description provides appropriate examples that support whether the Cedar Bend record policy for retention is compliant. C:SOURCES Not Evident The submission does not include both in-text citations and a reference list for sources that are quoted, paraphrased, or summarized. Approaching Competence The submission includes in-text citations for sources that are quoted, paraphrased, or summarized and a reference list; however, the citations or reference list is incomplete or inaccurate. Competent The submission includes in-text citations for sources that are properly quoted, paraphrased, or summarized and a reference list that accurately identifies the author, date, title, and source location as available. D:PROFESSIONAL COMMUNICATION Not Evident This submission includes pervasive errors in professional communication related to grammar, sentence fluency, contextual spelling, or punctuation, negatively impacting the professional quality and clarity of the writing. Specific errors have been identified by Grammarly for Education under the Correctness category. Approaching Competence This submission includes substantial errors in professional communication related to grammar, sentence fluency, contextual spelling, and/or punctuation. Specific errors have been identified by Grammarly for Education under the Correctness category. Competent This submission includes satisfactory use of grammar, sentence fluency, contextual spelling, and punctuation, which promote accurate interpretation and understanding. Supporting Documents Cedar Bend Record Policy.pdf Federal Policy for Retention and Destruction of Health Information_Accessible.docx Retention and Destruction of Health Information_Accessible.docx State A Health Information Retention and Destruction Statute.docx