Project #23808 - Medical Records Legal Project


  I.         Description:    Practical experience in identifying and comparing legal requirements for the medical record for state, federal, voluntary organizations, and other guidelines; researching and creating written documentation for the assigned topic.


A major written comparative and contrasting document based on an acute care setting is the principal focus of this project. This project requires knowledge and application of documentation requirements, research abilities, and analytical and critical thinking skills to investigate, select, compare and contrast legal requirements for Joint Commission, Medicare, HIPAA, and Kentucky State laws/standards for medical record legal requirements and/or recommendations.


II.         Competencies


A.     Demonstrate the ability to read, listen, interpret, and communicate through appropriate spoken or written forms of standard English.

B.     Demonstrate ability to recognize and critically examine differing documentation requirements.

C.     Demonstrate ability to apply differing documentation requirements to an acute care facility.

D.    Demonstrate ability to acquire, understand, process and draw conclusions from information using observation, analysis, interpretation, speculation, and evaluation.

E.     Demonstrate ability to identify problems and engage in problem-solving.

F.     Demonstrate the ability to learn new skills, new technologies, and develop new ideas.

G.    Demonstrate the ability to use basic literature searches and apply current technologies to retrieve, evaluate, and use information.

H.    Exhibit the ability to function effectively under conditions of ambiguity, uncertainty, and conflict.

      AHIMA Competencies: At the conclusion of this course, the student should be able to meet the following 2011 AHIMA HIM Associate Degree Entry-Level Competencies, Domains, Subdomains and Tasks:


I.      Monitor and apply organization wide health record documentation guidelines (I.B.1)

J.      Apply policies and procedures to ensure organizational compliance with regulations and standards (I.B.2)

K.     Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards (I.B.3)

L.     Assist in preparing the organization for accreditation, licensing, and/or certification surveys (I.B.4)

M.   Apply policies/procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care, and so forth (I.D.2)

N.    Apply current laws, accreditation, licensure and certification standards related to health information initiatives from the national, state, local, and facility levels (III.A.1)


III.         Medical Record Documentation Requirement Competencies


Apply legal requirements for the medical record to an acute care setting.

1)    Assess the legal requirements for a medical record by Joint Commission, Medicare, HIPAA, and Kentucky:

a)    Research appropriate on-line resources and information contained on Blackboard

b)    Compare and contrast requirements

2)    Develop a written table showing requirements (including narrative and reference number) and recommendations for medical records for an acute care setting and specify the most stringent requirement by bolding the entry in red.  This requirement would be adopted for the acute care setting.  Specific areas to review include:

a)    Basic requirements for a medical record, including what a medical record is and what it must contain

b)    Retention of medical records

c)    Release of Information, patient access and right to amend record

d)    Privileged information (info that speaks to Drug and Alcohol, Mental Health, HIV, etc) that have special requirements

e)    Age of majority, age of consent, and emancipated minors

f)      Documentation requirements for timeliness and content

1)    Complete medical record

2)    History and Physical

3)    Discharge Summary

4)    Operative Report

g)    Basic standards for Electronic Health Records


IV.         Specific Project Objectives


A.     Research legal requirements for the medical record from Joint Commission, Medicare, HIPAA, and Kentucky.

B.     Compare and contrast requirements between entities/standards.

C.     Utilize critical thinking and analytical skills to develop commonalities between entities.

D.    Utilize organizational skills to develop a visual table of legal requirements for the medical record.

E.     Identify those elements which must be incorporated into your requirements at your acute care setting.


V.         Specific Instructions:

A.     Conduct research to determine medical record requirements, as identified in “Medical Record Documentation Requirement Competencies” listed above.

B.     Develop grid (table) of standards (including numerical reference) for Joint Commission, Medicare, HIPAA, and Kentucky.   You may use n/a for not appropriate if a specific standard does not address a certain item.  You may use “defers to Kentucky State Law” or “references Joint Commission standards”, as appropriate. 

C.     Identify (by bolding, highlighting, or using red) the most stringent standard for each element in order to choose which one to implement at your acute care setting.

D.    You are required to use word processing or a spreadsheet for the grid (table).

E.     It must be in a printable, readable, user-friendly format.       

F.     Grading will be based on content as well as neatness/professionalism.

Subject Medicine
Due By (Pacific Time) 03/02/2014 11:00 pm
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