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A standardized format for the use of forms in the paper record and documentation screens in the electronic health record is necessary in order to enable accurate documentation and ease of location of information, whether in paper or electronically for patient care as well as other administrative uses of the record.
Select policies, procedures and guidelines provided for benchmarking in Module 01 under Benchmarking Resources based on appropriateness to this topic, or you may research policies, guidelines and standards on your own to use as a benchmark. Review your selected policies, procedures and guidelines and select the information after comparing those resources that you will include in your policy and write your policy on organization wide guidelines on forms control. Consider how new documentation capture tools can be recommended, approved and communicated to the health care providers.
The completed typed policy should be 1 page. If you use a source for the policy, state the source at the end of the policy under a heading titled references.
Please Meet Criteria
Policy includes appropriate, thorough, and detailed guidelines for forms control .
Applies correct spelling, grammar and a consistent policy format.
Sample Policy and Procedure
TITLE:
POLICY AND PROCEDURE WRITING
DEPT: HIM SERVICES
SUBMITTED BY:
DATE:
APPROVED BY:
DATE:
Effective Date:
Purpose
To provide a guide to writing and maintaining effective and uniform policies and procedures for an HIM Services Department.
Policy
To write effective and uniform procedures that will support the objectives of the services provided by the HIM Services Department.
Procedure
The following are specific tips for writing and maintaining effective procedures:
1. Begin each sentence with an action verb.
2. Number each step in the procedure paying careful attention to the sequence.
3. Keep all steps brief and concise.
4. Reference all related documents and/or policies necessary to complete tasks.
5. Write policy in a way that new team members will be able to be cross-trained with minimal assistance.
6. Ask a team member with experience with the task to perform it using the procedure ensure completeness.
7. Review all policies and procedures annually.
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