List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices

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Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. This small rural hospital is a 30-bed, fully paper-health dependent facility. Although the purchase and implementation of an EHR is not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes although the EHR is currently out of reach, the importance of developing a CDI program is ultimately, a step in the right direction. Revisit your Week 3 “Health Record Documentation Policy” (paper-based record policy only) and Week 4 “Data Quality Beyond Borders: Modernizing Health Information Infrastructure Using AHIMA’s Data Quality Model” assignments that has been critiqued by your Professor. Using both materials from weeks three and four, devise a five (5) to seven (7) page briefing to the Chief of Staff also known as the Chief Medical Officer which outlines the following listed below.

Deliverables:

Overview/description of the Clinical Documentation Improvement (CDI)
The benefits of implementing a CDI program
Consequences of not implementing such a program
List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices
The significant role of physicians as it relates to timely, accurate, complete and legible health record documentation practices and the timely response to physician queries within 48-72 hours upon receipt. Outline the process of the department’s physician query process
How the HIM department will lead the initiative. How the HIM staff can/will assist the Chief of Staff and the entire pool of practicing physicians
Include an attachment of your policy and checklist (from weeks three (3) and four (4)) with a brief explanation as an interpretation of both (not counted towards the five (5) to seven (7) page requirement; list as an appendix)
Finally, devise a 1-page six (6) month timeline which outlines the planning, designing and implementation of your proposed CDI program (not counted towards the five (5) to seven (7) page requirement; list as an appendix)

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