Reference no: EM133462390

Assignment:

A checklist of the most important elements that should be included in a documentation audit tool for hospital medical records. Determine a format that works best for this checklist.

• Include at least ten key elements that should be documented in the legal health record.
• To ensure the checklist is based on fact, and not just your opinion or perspective, you may use the articles provided for this assessment, McLaren Macomb policy, other credible sources, or any textbooks from other courses as references.

A summary of the importance of the elements you identified to be audited and how they relate to the seven criteria for high-quality clinical documentation. Consider the following questions:

• Explain why are these elements essential to audit.
• Justify how external regulations (CMS, HIPAA, etc.) affect the key elements of an audit.
• Describe the best course of action when deficiencies are identified.

Each time you refer to information gained from a source, make sure you indicate the source of information. It is vital to avoid plagiarism by giving credit to another author's ideas.