There are three main groups that share the responsibility for the healthcare organization’s compliance with the requirements for collecting and maintaining clinical data. The first group is the Healthcare Providers, the second group is the Healthcare Information Managers (HIM) and professionals, and the third group is the organization’s Health Record Committee. The three groups work together to ensure all compliance requirements are in place.
Regulations are in place for the requirements of collecting and maintaining clinical data including “statutory provisions, administrative regulations, accrediting standards, and professional guidelines” (Mcway, D p124). The Conditions of Participation in the Medicare program and the accrediting standards of the Joint Commission are the most significant requirements that the three groups must comply with.
The Healthcare Providers are the first to see the patient and they have the best opportunity to ensure compliance in collecting and maintaining clinical data. They ensure authorship, authentication, timeliness, and completeness of the health record, and all parts necessary for the integrity of the health record. The records should also show who the individual was that made the entry and recorded it in a timely manner, while containing all the information that reflects the care a patient received. Records can be in a paper form or in an electronic format that has been approved by the Health Record Committee.
The Health Information Managers (HIM) have intimate knowledge of the documentation guidelines and help providers determine how they will create templates, formats, notes, and other data elements (AHIMA Library). They assist the providers by having uniform policies in place and develop procedures that assist with the completion of incomplete records. One type of process might be prior to submitting a claim to the payer with a “Clean Claim” review takes place, a process...