Reference no: EM133793527

Question

HIM STANDARD: Written policies on record completion comply with and are consistent with accreditation standards, regulatory requirements, and medical staff guidelines. Records should be assembled, analyzed, and completed within 30 days of discharge unless state law specifies another time frame. A record should be removed from the nursing station as soon as possible after discharge within 24 - 48 hours, but no more than 72 hours after discharge. The initial assembly and analysis should take place within 5 days of discharge. This allows the remaining time to follow up on deficiencies and track documents that are mailed for completion and/or signature and still allow for timely completion of the discharge record. Incomplete and Delinquent Records HIM STANDARD: Written policies outline the organization's standards for the timely and accurate reporting of delinquent records. Upon completion of the discharge analysis, records that have specific deficiencies that can be completed by a health care provider are considered incomplete. After the audit has been completed, the providers should be notified of the incomplete records. They should be informed of the expectation to complete these records within a specific timeframe (within the 30 day or state-specific timeframe for timely completion of discharge records). Records should.