Question: Part 2: As the HIM Director, you will be reporting on authentication of the medical record by the medical staff at your hospital at the
Part 2: As the HIM Director, you will be reporting on authentication of the medical record by the medical staff at your hospital at the next Quality Improvement meeting. Your hospital does have some electronic components but not a fully electronic health record. After doing an audit of a sampling of records, you find that physician verbal orders and progress notes are not consistently dated, timed and authenticated, consultation reports are not authenticated, and some physician assistants without privileges are documenting in the medical records on behalf of their physician employers. To support your report, you must go to the Joint Commission eDition guidelines to prepare a document at least one page long discussing the concerns of the QI director. You will need to include a summary of the JC guidelines as well as the responsible party/parties. Remember, HIM does not create the Medical Staff Rules and Regulations, but we are often tasked with enforcing them! Note that you cannot cut and paste from the guidelines as there are serious consequences for plagiarism. Long quotations are not allowed either! Therefore, you need to discuss this in your own words. (30 points)
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