Reference no: EM133033638

There are two (2) parts to the assignment. In Part 1, you will be accessing the Conditions of Participation to review the standards and complete the grid in Part 1. 

In Part 2, you will utilize the information you obtained from the COP in Part 1 to audit the "Sample Medical Record Requirements Policy" for compliance with the standards. 

• In the Part 2 grid, indicate if the element is present in the policy and stated correctly by marking "X" in Column B. 
• If the standard is not present in the policy, mark "X" in Column C. 
• If there is reference to the element in the policy, but it is not stated correctly according to COP, mark "X" in column D 
  • AND enter the correct verbiage for the element in Column E.

Part 1

Instructions:

• Access Conditions of Participation (COP) via 
• Review the COP Standard to determine the Medical Record Requirements.
• Complete Column B in the Part 1 grid with the COP standard statement for each of the elements listed in Column A.

Column A	Column B
Element	Standards    (Responses should reflect the full intent of the COP Standard)
Example: Standing Orders
1. Medical Record  Maintained
2. Retention
3. Coding & Indexing
4. Release of Original Medical Records
5. Medical Record Entries and authentication
6. Orders
7.History & Physical (H&P) completion timeframes- a) Preadmission b) After admission c) Surgery with Anesthesia d) Updated H&P
8. Other record content includes (except discharge summary, final diagnosis and completion of medical record)
9. Discharge Summary Content
10. Final Diagnosis and Medical Record Completion Timeline

Part 2 

Instructions:

• Download and Audit the Sample Medical Records Requirements Policy provided in the assignment against the standards as noted in Part 1 under "Standards" for each element.
• Determine if the required elements in Column A are documented appropriately in the Sample Policy-- 
  • "Present-Correct" (Column B)
  • "Not Present"     (Column C) 
  • "Present-Incorrect (Column D)
    • If Present-Incorrect, Indicate how the policy statement should read per COP Standard (Column E)

Mark "X" in the appropriate column.

Note: Only one "X" per element.

Column A	Column B	Column C	Column D	Column E
COP Required Elements	Present Correct Mark "X"	Not Present Mark "X"	Present Incorrect Mark "X"	Record the Correct Statement per COP 482.24
Example: Standing Orders			X	May be used if such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership
1. Medical Record  Maintained
2. Retention
3. Coding & Indexing
4. Release of Original Medical Records
5. Medical Record Entries
6. Orders
7. History & Physical (H&P) completion timeframes- (a - d) a) Preadmission
b) After admission
c) Surgery with Anesthesia
d) Updated H&P
8. Record content includes (except discharge summary, final diagnosis and completion of medical record)
9. Discharge Summary Content
10. Final Diagnosis and Medical Record Completion Timeline