Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:The Role of Medical Records in U.S. Health Care
Slide content:Governance of Health Record Federal and State Laws, Regulations, and Rules The Joint Commission and other voluntary accreditation Medical staff bylaws 8
Slide notes:The components of the health record are governed by many different external agencies. These may include federal and state laws, regulations, and administrative rules. Voluntary accreditation, such as by The Joint Commission, introduces requirements for documentation in the health record. At the health care facility level, m edical staff bylaws also provide direction for completion and maintenance of documentation in the health record. It is difficult to keep abreast of all the changes occurring in health record policies. Facilities must develop compliance plans to make sure that external and internal rules are followed. The director of a health information management department must stay up to date on legislative and accreditation changes that affect requirements for documentation in the health record. Key areas of focus include medical coding, reimbursement laws and regulations, and privacy of patients health information. Clinical departments within a health care organization must monitor new laws and regulations for their respective areas. In addition, each facility should also have an oversight committee, department, and/or director to ensure overall compliance with documentation requirements. 8