Compliance of Health Record Content 2018 AHIMA Competencies
I.2 Apply policies, regulations, and standards to the management of information
(3) I.4 Determine compliance of health record content within the health organization
(5) VI.1 Demonstrate fundamental leadership skills
(3) VI.9 Identify processes of workforce training for health care organizations
1. Access health record from sources: G-drive, EHRGo, VLab, Bb, etc.
2. Post source, patient name, and number
3. Determine if patient was inpatient or outpatient.
4. Determine the type of care: Physician Office, Clinic, ER, Hospital, Rehab, etc.
5. Respond to the completeness (quantitative analysis) of the health record (signatures, time stamped, and auditing for deficiencies). List health reports that are expected within the health record.
6. Review and list health reports expected to be a part of this health record (qualitative analysis). Examine the content of each entry for completeness.
7. Code only principal diagnosis posted on health record
8. Associate appropriate ICD-10-CM code to Official Guideline for Coding and Reporting