What does it mean to a facility to be accredited by the Joint Commission?

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InstructionsMuch of this course is dedicated to educating you, the student, about compliance with quality standards. It is important to understand that compliance extends to every phone call, computer

Instructions

Much of this course is dedicated to educating you, the student, about compliance with quality standards. It is important to understand that compliance extends to every phone call, computer entry, claim submission, patient contact, visit, provider interaction, nursing care and so on. For this, your Final project, you will prepare a report about the role of the Joint Commission (JC).

To begin, please visit the Joint Commission website:

Source: The Joint Commission: The Joint Commission. Retrieved from http://www.jointcommission.org/

Additional research will be necessary. Please visit the Library for your research.

Part I

  • Write an essay discussing the following:
    • The role of the Joint Commission in accrediting medical facilities
    • Which facilities can be accredited?
    • What are the goals of the Commission?
    • How do existing Joint Commission guidelines impact facilities that are not accredited by the Commission?
    • What does it mean to a facility to be accredited by the Joint Commission?
    • Is it mandatory for organizations to be accredited by the Joint Commission? If not, what impact does not having such accreditation mean in terms of reimbursement?Part II
  • Create a memorandum where:
    • You are the administrator of the health information department for a medium-sized facility. You have just been informed by the compliance officer that the Joint Commission will be visiting your facility and will be focusing on your department.
    • Begin the memorandum by including information you believe will be important for your personnel to know to prepare for the visit.
    • Then, anticipate possible questions that the Commission might have for you in terms of compliance.
    • How will you and your department respond to these questions? How will you manage any negative findings during the visit?
    • Finally, discuss how current noncompliance findings can be avoided in the future in this memorandum.Requirements
  • Complete both part of the Assignment as follows:
    • Part I should cover 4–5 pages
    • Part II should cover 2–3 pages
  • Use the Joint Commission website as one source and at least two other sources for your topic — a minimum of three references total.
  • All formatting and references should use APA style.
  • Total of 8–10 pages including the title page and reference page.

Did understanding the state laws confirm or challenge your initial recommendation regarding involuntarily committing the client? Explain.

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Scenario for Week 7 Case:You are a PMHNP working in a large intercity hospital. You receive a call from the answering service informing you that a “stat” consult has been ordered by one of the hos

Scenario for Week 7 Case:

You are a PMHNP working in a large intercity hospital. You receive a call from the answering service informing you that a “stat” consult has been ordered by one of the hospitalists in the ICU. Upon arriving in the ICU, you learn that your consult is a 14 year old male who overdosed on approximately 50 Benadryl (diphenhydramine hydrochloride) tablets in an apparent suicide attempt. At the scene, a suicide note was found indicating that he wanted to die because his girlfriend’s parents felt that their daughter was too young to be “dating.” The client stated in the suicide note that he could not “live without her” and decided to take his own life. Although he has been medically stabilized and admitted to the ICU, he has been refusing to talk with the doctors or nurses. The hospital staff was finally able to get in touch with the clients parents (using contact information retrieved from the 14 year old’s cell phone). Unbeknown to the hospital staff, the parents are divorced, and both showed up at the hospital at approximately the same time, each offering their own perspectives on what ought to be done. The client’s father is demanding that the client be hospitalized because of the suicide, but his mother points out that he does not have “physical custody” of the child. The client’s mother demands that the client be discharged to home with her stating that her son’s actions were nothing more than a “stunt” and “an attempt at manipulating the situation that he didn’t like.” The client’s mother then becomes “nasty” and informs you that she works as a member of the clerical staff for the state board of nursing, and if you fail to discharge her child “right now” she will make you “sorry.” How would you proceed?

To Prepare for this Practicum:

  • Review the Learning Resources concerning voluntary and involuntary commitment.
  • Read the Week 7 Scenario in your Learning Resources.
  • Research your state’s laws concerning voluntary and involuntary commitment.

The Assignment (2–3 pages):

  • Based on the scenario, would you recommend that the client be voluntarily committed? Why or why not?
  • Based on the laws in your state, would the client be eligible for involuntary commitment? Explain why or why not.
  • Did understanding the state laws confirm or challenge your initial recommendation regarding involuntarily committing the client? Explain.
  • If the client were not eligible for involuntary commitment, explain what actions you may be able to take to support the parents for or against voluntary commitment.
  • If the client were not eligible for involuntary commitment, explain what initial actions you may be able to take to begin treating the client.

Describe strategies team members can use to build trust among one another in terms of skill, knowledge, and responsibility.

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ITS IMPORTANT TO MEET THE COMPETENCES !!!Prepare a 10–12-slide PowerPoint presentation for department managers on building leadership and trust in collaborative teams.    Perhaps the best predict

ITS IMPORTANT TO MEET THE COMPETENCES !!!

Prepare a 10–12-slide PowerPoint presentation for department managers on building leadership and trust in collaborative teams.    

Perhaps the best predictor of team success is its clarity of purpose and the team’s commitment to achieving it. To support that purpose, a team needs a process that moves smoothly from vision and mission to goals and tasks in order to achieve the desired outcomes. The foundation of both purpose and process is leadership.

Any form of collaboration is an inherently human process. The culture of an organization can dramatically affect team efficacy and performance. The glue that holds teams together is trust. Three factors can help build trust in collaborative environments: performance and competence, integrity, and concern for the well-being of others.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Explain strategies for effective interprofessional teamwork and collaboration in health care delivery.            
    • (IMPORTANT) -Identify leadership behaviors that build trust and undermine trust within teams.
    • (IMPORTANT) -Describe strategies team members can use to build trust among each other.
    • (IMPORTANT) -Describe principles of effective interprofessional team leadership.
  • Competency 2: Analyze the implications of working with interprofessional teams in multifaceted health care settings.            
    • (IMPORTANT) -Explain the consequences of a team that does not trust its leader in terms of patient safety.
  • Competency 4: Communicate in a manner that is scholarly, professional, and consistent with expectations of a nursing professional.            
    • (IMPORTANT) -Write content clearly and logically, with correct use of grammar, punctuation, and mechanics. Use correct APA format.

Assessment Instructions 

Requirements

You have been asked by organizational leadership to develop a PowerPoint presentation for department managers on building leadership and trust in collaborative teams. Your presentation should be 10–12 slides in length and include a references slide at the end. Use the notes section of each slide to expand your talking points and reference your resources. Be sure your references are formatted according to APA guidelines.

This assessment examines two critical components for interprofessional team success: leadership and trust. Develop a PowerPoint presentation in which you:

  • Identify at least three leadership behaviors that build trust within a team.
  • Identify at least three leadership behaviors that undermine trust within a team.
  • Explain the consequences of a team that does not trust its leader in terms of patient safety.
  • Describe strategies team members can use to build trust among one another in terms of skill, knowledge, and responsibility.
  • Describe principles of effective interprofessional team leadership. In other words, what skills and qualities should a good team leader possess? Is there a difference between being a good leader and being an effective leader?

Additional Requirements

  • Include a title slide and references slide.
  • Create 10–12 slides in addition to the title and references slides.
  • Use at least three current scholarly or professional resources.
  • Use APA format for references.
  • Be creative. Consider your target audience.

Explain the influence of altruistic organizations (Peace Corps, Project Hope, religious and non-religious missions, and so on) on health and health care practices in the global area specifically associated with the topic.

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Develop a 6–8 page, APA-formatted article on a global health topic for publication. Describe the factors that impact health and health care delivery, and the interventions that have been implemented.

 Develop a 6–8 page, APA-formatted article on a global health topic for publication. Describe the factors that impact health and health care delivery, and the interventions that have been implemented. Explain the influence of altruism on global health, and identify evidence-based interventions to address the global health topic. 

Preparation

Suppose you have been asked to submit an article for publication in your organization’s newsletter, about a global health topic and how policies and practices at the local level can affect global health. Choose one global health topic from the list (or use another of your choice):

  • Mental health.
  • Communicable diseases (HIV/AIDS, influenza, malaria, tuberculosis).
  • Non-communicable diseases (cancer, lung, and heart disease).
  • Maternal and child health (prenatal care, midwife education, childhood vaccinations).
  • LGBT health.
  • Disabilities.
  • Global water supply and safety (GlobalHealth.gov, n.d.).

Look on the Internet for very recent peer-reviewed articles, statistics, and professional nursing information on the global health topic you selected.

Requirements

For this assessment, develop an APA-formatted research review article that covers one global health topic of your choice. In this assessment:

  • Identify your topic. Provide background information and statistics on the topic, including the global areas most affected by the topic and the types of health care issues most often associated with the topic.
  • Describe the factors that impact health and health care delivery in the global areas most affected by the topic you selected. These factors may include not only culture and tradition, but also politics, economics, and social attitude.
  • Explain the influence of altruistic organizations (Peace Corps, Project Hope, religious and non-religious missions, and so on) on health and health care practices in the global area specifically associated with the topic.
  • Describe the interventions implemented to address the health care issues associated with the topic. Include both conventional and unconventional interventions.
  • Explain how the health care decisions and practices at the local level (the area most impacted by the topic) relate to health and health care delivery in other global areas. This is not limited only to best practices, but could include poor health care decisions and practices.
  • Identify evidence-based interventions that are effective, efficient, cost-effective, and equitable for promoting wellness and disease prevention in the specific area and population.

Additional Requirements

Complete your assessment using the following specifications:

  • Title page and reference page.
  • Number of pages: 6–8 (not  including the title and reference pages).
  • At least 3 current scholarly or professional resources.
  • APA format for citations and references.
  • Times New Roman font, 12-point, double-spaced.

CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)

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NR 305 Week 3 Assignment Family Genetic History

This paper of NR 305 Week 3 Assignment Family Genetic History gives the solution to:

This assignment is to help you gain insight regarding the influence of genetics on an individuals health and risk for disease. You are to obtain a family genetic history on a willing, non-related, adult participant.

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO #3: Utilize effective communication when performing a health assessment. (PO #3)

CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)

Points

This assignment is worth a total of 100 points.

Due Date

The Family Genetic History Assignment is to be submitted at the end of Week 3. There is a MS Word document form in Doc Sharing that you need to download, fill in, and submitto the Family Genetic History Dropboxby Sunday, 11:59 p.m. MT at the end of Week 3. Post questions to the weekly Q A Forum. Contact your instructor if you need additional assistance.See the Course Policies regarding late assignments. Failure to submit your paper to the Dropbox on time may result in a deduction of points.

Disclaimer

When taking a family genetic history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the adult participant decides not to share information, please write, Does not want to disclose.

Directions

Refer to the examples in Chapter 10 of your textbook discusses development of a genogram.

Download the NR305_Family_Genetic_History_Form from Doc Sharing. You will document the adult participants family genetic history using this MS Word document.

Complete the family genetic history using the information that the adult participant is willing to share with you. The focus of this course is on the normal healthy individual so your paper does not need to contain much medical/nursing detail. Refer to your textbook or the internet to learn what impact the familys health history may have on the adult participants personal state of wellness both now and in the future.

This paper does not require APA formatting, but you are expected to write clearly and use proper grammar and spelling.

Developing a pictorial genogram using symbols to identify certain relationships, e.g., divorced, sibling, deceased, etc., may provide more insight, however, drawing may be difficult to accomplish with MS Word, therefore you are not expected to use symbols, lines or other drawing elements. Instead, describe the relationships among the various people in the adult participants familys genetic history. Remember, the goal is not to learn how to draw with Word, but to gather information about the family and recognize its significance to the adult participant and that persons health.

Save the completed form by clicking on Save as and add your last name to the file name, e.g., NR305_Family_Genetic_History_Form_Smith

Submit the completed form to the Family Genetic History basket in the Dropbox

CO 4: Identify teaching/learning needs from the health history of an individual. (PO #2)

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Part One of the Assignment.PurposeTo create a Patient Teaching Plan aimed at educating a specific patient population about a specific health topic. This plan will be used to develop a Visual Teachin

 Part One of the Assignment.

Purpose

To create a Patient Teaching Plan aimed at educating a specific patient population about a specific health topic. This plan will be used to develop a Visual Teaching Tool in a future assignment.

Course Outcomes

This assignment enables the student to meet the following course outcomes.

  • CO 2: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO #1)
  • CO 4: Identify teaching/learning needs from the health history of an individual. (PO #2)

This assignment is worth 125 points.

Background Information

NR305 focuses on nursing assessment, and the identification of opportunities to prevent disease and improve health of patients. An important professional role for nurses is to provide teaching to patients based on knowledge deficits identified during assessment.

Prior to beginning this assignment, follow the link to read the article below. The information related to adult learning and barriers to understanding will be helpful when planning how to best educate your selected population.

Beagley, L. (2011). Educating patients: Understanding barriers, learning styles, and teaching techniques. Journal of Paranesthesia Nursing, 26(5), 331-337. permalink (Links to an external site.)Links to an external site.

Directions

Please read all directions carefully before you begin.

  1. Click to download the Patient Teaching Plan Form (Links to an external site.)Links to an external site.. Type your answers directly into this Word document and submit. The use of correct terminology, grammar, and spelling is important! Any references and citations used should be written in APA format. Please utilize in-text citations when appropriate, and list all references in the space provided at the end of the worksheet.
  2. You are required to complete the form using the productivity tools required by Chamberlain University, which is Microsoft Office Word 2013 (or later version), or Windows and Office 2011 (or later version) for MAC. You must save the file in the “.docx” format. Do NOT save as Word Pad. A later version of the productivity tool includes Office 365, which is available to Chamberlain students for FREE by downloading from the student portal at http://my.chamberlain.edu (Links to an external site.)Links to an external site.. Click on the envelope at the top of the page.
  3. Health Topic: Decide WHAT you would like to teach. Describe in detail why this is an important topic for patient education. Use evidence from the textbook, lesson or an outside scholarly source to support your rationale.Select from the following health topics to complete your Patient Teaching Project:
    • Stress and Time Management
    • Self-Care (can choose a specific self-care activity)
    • Prevention of Hazards at Work
    • Bicycle Safety
    • Ergonomics (related to work, posture)
    • Skin Cancer Prevention
    • Healthy Eating
    • Exercise/Physical Activity
    • Suicide
    • Human Trafficking
    • Eating Disorders
    • Substance Abuse (Opioid, Alcohol, Nicotine)
    • Depression
    • Palliative Care/Hospice Care
  4. Population and Setting: Once you have selected a topic, you must decide WHOyou will be teaching and WHERE the education will take place. (i.e., teaching a classroom of middle school students; teaching community members at a local health fair)
  5. Learning Barriers: Refer to the assigned article: Educating patients: Understanding barriers, learning styles, and teaching techniques for information related to learning barriers and other teaching considerations. Barriers might be cultural, physical, educational, or environmental. You may also want to consider the developmental stages of your selected population.Example:
    • The population in this community is known to have a low-literacy level, therefore clear pictures and graphics will be utilized to assist with understanding.
  6. Learning Objectives: Write three specific learning objectives your Visual Teaching Tool will address. Begin each objective with “At the end of this education, the learner will …” Use an action verb to finish the sentence (i.e., list, demonstrate, describe, define, identify).Example:
    • At the end of this education, the learner will be able to demonstrate the proper way to wear a bike helmet.
    • At the end of this education, the learner will be able to describe how to perform a breast self-exam.
    • At the end of this education, the learner will be able to list three benefits of regular physical activity.
  7. Evaluation: Write a paragraph describing how you could evaluate whether your visual teaching tool was successful and met the learning objectives. Consider the population’s abilities and the setting.

PART 2 OF THE ASSIGNMENT

Purpose

To utilize the Patient Teaching Plan (developed in a prior assignment) to create a Visual Teaching Tool to educate the selected patient population about the selected health topic.

Course Outcomes

This assignment enables the student to meet the following course outcomes.

  • CO 2: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO #1)
  • CO 4: Identify teaching/learning needs from the health history of an individual. (PO #2)

This assignment is worth 75 points.

Select an Option to Complete this Assignment

There are 3 options for creating your Visual Teaching Tool. Be sure to choose a format that makes sense for your selected topic, population, and setting. For example, if will be teaching adults at a health fair, then an educational brochure would be an appropriate choice. You must use the Patient Teaching Plan you have developed in this course to create your Visual Teaching Tool.

Option #1 – Power Point

Directions: 

  1. Create a 6-8 slide Power Point presentation for your selected population setting.
  2. The goal of this Power Point Presentation is to address the three learning outcomes you developed in the Patient Teaching Plan. Once the learner has viewed your Power Point, all three of the learning objectives should have been met.For Example:If a learning objective in the teaching plan is: “At the end of this education, the learner will be able to demonstrate the proper way to wear a bike helmet,” then there should be content in your Power Point related to how to properly wear a bike helmet.
  3. Tips for a great Power Point presentation:
    • Be creative! Choose a design (from the design tab of the PowerPoint presentation) to enhance visual appeal.
    • Incorporate graphics, clip art, or photographs to increase interest.
    • Use words and phrases suitable for your selected population.
    • Avoid writing paragraphs. Use simple sentences and bullet points.
    • Cite all sources used to create the educational content with (author, year).
    • Proofread for spelling and grammar errors prior to final submission.
  • NOTE: The Patient Teaching Plan Form and the Article are the attachment below. You can use additional Article.

Create an educational presentation for staff before the launch of your change project.

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Educating the Staff

PLEASE SEE ATTCHED FOR THE SUBJECT FOR THE POWERPOINT

PurposeThe purpose of this PowerPoint presentation is to create the Educating Staff: Implementing Change Project PowerPoint presentation. Your plan is to educate the staff that will be involved in the pilot program. You will need to educate them on the problem, show the supporting evidence, and how your pilot plan will be implemented.Directions    •    Create an educational presentation for staff before the launch of your change project. This should inform the staff of the problem, your potential solution, and their role in change project.     •    The format for this proposal will be a PowerPoint presentation.    •    The length of the PowerPoint presentation should be 15-20 slides; excluding the title and reference slides.    •    Below are the topics for the slides:    •    Title slide    •    Description of the change model used    •    PICO question—include the elements    •    Scope of the problem—use statistics    •    Your team/stakeholders    •    Evidence to support your need for change—from research     •    Action Plan     •    Timeline for the plan    •    The nurses role and responsibility in the pilot program    •    Procedure     •    Forms that will be used (if applicable)    •    Resources available to the staff—including yourself    •    Summary    •    References    •    Citations and References must be included to support the information within each topic area. Refer to the APA manual, Chapter 7, for examples of proper reference format. Citations are to be noted for all information contained in your paper that is not your original idea or thought. Ask yourself, “How do I know this?” and then cite the source. Scholarly sources are expected, which means choose peer-reviewed journals and credible websites.Guidelines    •    Application: Use Microsoft PowerPoint 2010.    •    Length: The PowerPoint slide show is expected to be between 15-20 slides in length (not including the title slide and reference list slide).    •    Tutorial: For those not familiar with the development of a PowerPoint slideshow, the following link to the Microsoft website may be helpful. http://office.microsoft.com/en-us/support/training-FX101782702.aspx The Chamberlain Student Success Strategies (CCSSS) offers a module on Computer Literacy that contains a section on PowerPoint. The link to SSP CCSSS may be found under the Special Courses list in eCollege.Best Practices in Preparing a PowerPoint PresentationThe following are best practices in preparing this project.     •    Slides should be easy to read with short bullet points and large font. Do not use paragraphs.    •    Be creative, but realistic with your intervention and evaluation tool.    •    Incorporate graphics, clip art, or photographs to increase interest.    •    Review directions thoroughly.    •    Cite all sources within the slide show with in-text citations, as well as a reference page.    •    Proofread prior to final submission.    •    Spell check for spelling and grammar errors prior to final submission.    •    Abide by the Chamberlain College of Nursing academic integrity policy.

Personal Health and Wellness

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PROFESSOR MITCH

Personal Health and Wellness

___________________________________

DISCUSSION BOARD

The Aging Process

The aging process is a complex interaction of genetic and environmental factors; therefore each individual ages differently. For example, changes in body composition, body weight, and body systems are common effects of aging. It is essential for those who are aging to maintain a healthy lifestyle to reduce the risk of disease and infection. However, the end result of aging inevitably is death. Appropriate preparation for death contributes to well-being of family and friends and brings peace of mind to the dying.

For this Discussion, consider the impact of aging on personal health and wellness and the importance of preparing for death. To prepare for this Discussion:

  • Review Chapter 14 in Health: The Basics, 10th edition. Pay particular attention to aging and preparing for death.
  • Complete the Chapter 14 Personal Health Assessment “Are You Afraid of Death?” in Health: The Basics, 10th edition.
  • Think about preparing for death.
  • Review the media “Dimensions of Health Wheel.” Select two dimensions of health and consider how the aging process might affect each of them.

With these thoughts in mind:

Select one of the two Discussion Questions.

By Day 4, post a brief description of the two dimensions of health you selected. Then explain how the aging process might affect those dimensions. Finally, describe one strategy you might recommend to improve or enhance the two dimensions of health you selected for someone who is aging.

OR

By Day 4, post an example of a situation in which preparation for death was either adequately planned or inadequately planned. Explain the results and the impact of those results on family and friends. Finally, explain how this situation might influence your own preparations for death and dying.

_____________________________________________________________________

___________________________________

RESOURCES

  • Donatelle, R. J. (2013). Health: The basics, 10th edition. San Francisco, CA: Pearson Benjamin Cummings.
    • Chapter 12, “Reducing Your Risk of Cardiovascular Disease and Cancer”
    • Chapter 13, “Protecting against Infectious and Noninfectious Diseases”
    • Chapter 14, “Preparing for Aging, Death, and Dying”
  • Meetoo, D. (2008). Chronic diseases: The silent global epidemic. British Journal of Nursing (BJN), 17(21), 1320–1325. Retrieved from the Walden Library databases.
  • Luepker, R. V. (2011). Cardiovascular disease: Rise, fall, and future prospects. Annual Review of Public Health, 32, 1–3. Retrieved from the Walden Library databases.
  • Document: Final Project Guidelines (.pdf document)Note: This document provides guidlines and requirements for your final project.

Media

  • Laureate Education, Inc. (Executive Producer). (2012). Personal Health and Wellness: Dimensions of Health Wheel [Multimedia], Baltimore, MD: Author.
    • Dimension of Health: Week 5

Optional Resources

  • Phelan, E. A., Anderson, L. A., LaCriox, A. Z., & Larson, E. B. (2004). Older adults’ views of “successful aging” — How do they compare with researchers’ definitions? Journal of The American Geriatrics Society, 52(2), 211–216. Retrieved from the Walden Library databases.
  • Emanuel, L., Bennett, K., & Richardson, V. E. (2007). The dying role. Journal of Palliative Medicine, 10(1), 159–168. Retrieved from the Walden Library databases.

Deliverables: Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation. Select from the following list of topics to choose from:

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Health Record Documentation Policy

As the recently hired Corporate Director of Health Information Management, you have tasked the assignment of creating a much needed policies to govern the practice of health record documentation. You have appointed your HIM Manager to devise such policies adhering to the format listed below. Submit one (1) single presentation.

Deliverables: Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation. Select from the following list of topics to choose from:

  • The Use of Electronic signatures/Authentication
  • Legibility
  • Electronic Health Record Duplication
  • Health Record Amendments
  • The Completion of Health Records (adhering to the JC timeline)
    • this includes the various forms (components within the Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)
  • Verbal & Telephone Orders
  • The use of departmental/organizational wide abbreviations
  • The Physician Query Process
  • The Use of MACRA& Meaningful Use (MU) Audits
  • Authorized Users
    • Training & Education
    • Password Protection and Updates
  • Copy & Paste Functionality
  • Cloned Documentation
  • Templates/Screen Designs

Health Record Policy Layout Format:

  • Subject
  • Purpose
  • Staff
  • Effective Date
  • A thorough description of the policy
  • Definition of Terms (associated with policy)
  • Procedure

Resources:

Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update): http://library.ahima.org/doc?oid=300257#.WHkS_lVpHIV

Fundamentals of the Legal Health Record and Designated Record Set: http://library.ahima.org/doc?oid=104008#.WHkTVFVpHIU

Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html

MACRA & MU: http://www.fiercehealthcare.com

Sample Compliance Checklists for Electronic Health Records: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-compliance-checklist.pdf

World Health Organization: GUIDANCE ON GOOD DATA AND RECORD MANAGEMENT PRACTICES: http://www.who.int/medicines/areas/quality_safety/quality_assurance/Guidance-on-good-data-management-practices_QAS15-624_16092015.pdf

ESaay nursing paper and ecxel file. Essay should be around 2 pages

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DUE IN 4 HOURS

ESaay paper and ecxel file. Essay should be around 2 pages

Learning Outcome: Construct information architectural models

Additional Reading:  Data Mapping and Its Impact on Data Integrity.  AHIMA. 2013  http://bok.ahima.org/PdfView?oid=107154

1.   Designation

Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).    For this assignment, you will access an excel file that contains some of the documents or files that are to be reviewed.  See above link for template.  This is not an exhaustive list.  For each element, you will indicate the primary source of the document.  For example, if your institution has an electronic capture of consent forms, then the source would be the EHR documentation system.  But if consent forms are still done via a paper form, then you would indicate that the source is paper.   Examples of the primary sources are given below.  This is not a complete list, so if your institution has a different source for the information, you are free to use that. 

Examples of Primary Sources

    Paper

    CPOE

    Nursing documentation system

    EHR documentation system

    PACS (Picture Archiving and Communication System)

    Transcription

    Financial System

    Administration system

    Admitting documentation system

You will also indicate if the document/file is part of the Designated Record Set or the Legal Health Record. Part of the assignment includes formatting the file in a way that is user friendly to the reader.  This may include regrouping some of the items, using shading or borders to help the end user find information, or you may need to add additional columns to capture the information you feel is important (although additional columns are not required).  If your entries do not fit into the template column width, please format so that the entry is wrapped in the cell.

The comment section can be utilized for any clarification you may wish to make.

2.   Retention

 In addition, you will research the retention requirements for these documents.  In some areas, there are no specific guidelines.  It is up to the institution to determine the retention period.  If you cannot find a specific time period, either check with your institution, or use your best judgement and indicate your reasoning in the comment section.

 Resources

State Medical Record Laws.  Table A-7. HealthIT.   https://www.healthit.gov/sites/default/files/appa7-1.pdf

 Retention and Destruction of Health Information.  AHIMA.  2013.  (http://library.ahima.org/PB/RetentionDestruction#.V9LcAzW8JsU

3.   Reflection

Write a two -three paragraph reflection on how this exercise (identifying the source and type of document) will help when mapping the components and structuring an EHR.