While it is important to have the right elements and data sets in medical records, Health Information Management (HIM) must ensure they know how, when, and by whom is accessing the protected health information (Luke, 2017). To ensure quality patient records, HIM has several policies and procedures in place (Gartee, 2011). These are often part of the regulations for the accreditation of the healthcare organization.
Some of the policies in place are to ensure proper documentation. This will allow for uniformity of documentation within the chart (Gartee, 2011). This allows for standardization that they are organized systematically. Also, it is important to know who is accessing the chart. This should only be done by individuals who are
Some of the policies in place are to ensure proper documentation. This will allow for uniformity of documentation within the chart (Gartee, 2011). This allows for standardization that they are organized systematically. Also, it is important to know who is accessing the chart. This should only be done by individuals who are