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There are many abbreviations used for the health record, health data sets and databases as evidenced in your reading for this module. As preliminary preparation for writing your organization wide policy on the use of acronyms and abbreviations in the health record, pick 20 of these abbreviations from your reading and design a table that gives the abbreviation and the meaning of the abbreviation. Consider this example as part of how you might include an abbreviation list/table within the policy.
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 for the use of acronyms and abbreviations. What other information might be helpful to include in this type of policy besides the title and the definition of acceptable or unacceptable acronyms and abbreviations.
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
Table shows 20 abbreviations and their meaning.
Policy includes appropriate guidelines for the use of acronyms and abbreviations.
Applies correct spelling, grammar and a consistent policy format
Benchmarking against other organizations polices and/or available guidelines is an important step in the process of developing or revising polices and guidelines for a healthcare organization. Below is a list of benchmarking resources links to policies and guidelines and standards which relate to the topics you will be preparing policies for during the course project. You may select from the list for sources you would use to benchmark in each module and cite those that you use as a reference at the end of your policy or you may research policies, guidelines and standards on your own to use as a benchmark.
Banner Health “Documentation Requirements for the Medical Record-Policy and Procedure
Pennsylvania Hospital & Surgery Center Administrative Policy Manual – Medical Record Documentation Practices
Kansas County Health Department- Medical Records Policy
Joint Commission – “Do Not Use” List
UTMB Policy Manual
UTMB Health Procedure – Prohibited Abbreviations
UTMB Handbook of Operating Procedures-Policy Patient Right and Responsibilities
Creighton Health Sciences School Policy_ Patient Rights and Responsibilities
TennDent Policy HIPAA Access Control
University of Tennessee Health Science Center: Access to Protected Health Information
Illinois Administrative Code Joint Committee on Administrative Rules Part 250 Hospital Licensing Requirements
HCA Policy – Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance Requirements
UCSD Health Sciences Compliance/Privacy Program “Comparison of HIPAA’s 18 Protected Health Information (PHI) vs. Limited Data Set (LDS)
University of California – Legal Medical Record Standards Policy
Federal Register – Security and Electronic Signature Standards
Federal Register- Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Order; Securing Medications; and Post anesthesia Evaluations
AHIMA Online Research Journal Perspectives in HIM: “Storage Media Profiles and Health Record Retention Practice Patterns in Acute Care Hospitals”, by Laurie A. Rinehart-Thompson
AHIMA Practice Briefs and Papers Electronic Signature, Attestation, and Authorship
Clinical Documentation Toolkit (AHIMA Body of Knowledge)
An additional source to perform you own external review of policies, procedures, guidelines and standards is through:
Textbook: Health Information Management Concept, Principles and Practice – Appendix D Web Resource
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