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Create Health Information Documentation Guidelines

SSIGNMENT: Create Health Information Documentation Guidelines

CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation

  • <l1>Compile organization-wide health record documentation guidelines

Please review the assignment instructions below, and each of the deliverables:

Scenario: You are the new HIM Director for Community Healthcare which includes an 1) acute care hospital, an 2) attached clinic and an 3) attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines.

You first need to compile the guidelines set forth by the CMS since those are the regulatory bodies that monitor your organization.


  1. Locate the documentation standards for the CMS Conditions of Participation.
  2. Create a table listing medical record documentation standards for CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic (RURAL HEALTH), and Longterm Care). You will have 3 tables, one for each type of facility.   See the websites for each type of facility for your table.


CoP Changes:

Clinic/Rural Health:

Section 491.10

Long Term Care Facilities:   (Pages 15, 57, 120, 193, 365-7, 371, and 453 within the document)

3.  Title the document as a policy and write a short explanation of the purpose of the document and how it should be used.   Please place in a memorandum format (non-APA, but more as if this were an actually requirement for your job), addressed to the Chief Information Officer of the facility.  Please place the references at the end.


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