1
WGU C811 Data Analytics and Information Governance
Task 4 | Passed on First Attempt |Latest Update with
Complete Solution
HEALTH RECORDS DOCUMENTATION AND STORAGE
Your Name
College of Health Professions, Western Governors University
Name of Instructor
Date
HEALTH RECORDS DOCUMENTATION AND STORAGE
(Prepare this as a rough draft to use Grammarly and insert citations and
the corresponding reference document information – then transfer the
headers to the individual slides and the complete sentences/paragraphs to
the Presenter Notes on each slide.)
TITLE SLIDE (NO PRESENTER NOTES ON THIS SLIDE, BUT MAKE SURE BOTH
STUDENT ID AND STATE COVERED IN WORK ARE ON TITLE SLIDE)
A history and physical examination are the most important steps when documenting a patient's
encounter. The Joint Commission has created some national standards for medical facilities to
follow. However, each state can create its standards; in this presentation, we will evaluate the
standards required by the Joint Commission and the state of Ohio.
, 2
SIMILARITIES
Joint
H&P Regulations State of Ohio
Commission
Must be created by a licensed physician X
Must contain a patient's chief complaint X X
Must have complete family and social history X X
H&P can be completed within 30 days prior to admission
X X
or registration
H&P is required for high-risk procedures, surgical
procedures, and any procedure that involves anesthesia X X
services
H&P is required for all inpatient admissions X
The Joint Commission (TJC) and the state of Ohio have very similar history and physical
documentation standards. TJC and the state of Ohio require that the history and physical
documentation be very detailed, including a chief complaint and a complete family and social
history. For both, a history and physical exam must be required for any high–risk procedures,
surgical procedures, and any procedures involving anesthesia services. Also, both standards
allow the history and physical to be completed up to 30 days in advance.
DIFFERENCES
Joint
H&P Regulations State of Ohio
Commission
Must be created by a licensed physician X
Must contain a patient's chief complaint X X
Must have complete family and social history X X
H&P can be completed within 30 days prior to admission
X X
or registration
H&P is required for high-risk procedures, surgical
procedures, and any procedure that involves anesthesia X X
services
H&P is required for all inpatient admissions X
The Joint Commission and the State of Ohio did not have many differences. The first difference
identified is that the Joint Commission requires a qualified physician or licensed practitioner to
be granted the privilege of creating the history and physicals (The Joint Commission, n.d.). The
state of Ohio not only lets qualified physicians or licensed practitioners create history and
physical documentation, but the medical staff and their designees can also document it (Ohfama,
WGU C811 Data Analytics and Information Governance
Task 4 | Passed on First Attempt |Latest Update with
Complete Solution
HEALTH RECORDS DOCUMENTATION AND STORAGE
Your Name
College of Health Professions, Western Governors University
Name of Instructor
Date
HEALTH RECORDS DOCUMENTATION AND STORAGE
(Prepare this as a rough draft to use Grammarly and insert citations and
the corresponding reference document information – then transfer the
headers to the individual slides and the complete sentences/paragraphs to
the Presenter Notes on each slide.)
TITLE SLIDE (NO PRESENTER NOTES ON THIS SLIDE, BUT MAKE SURE BOTH
STUDENT ID AND STATE COVERED IN WORK ARE ON TITLE SLIDE)
A history and physical examination are the most important steps when documenting a patient's
encounter. The Joint Commission has created some national standards for medical facilities to
follow. However, each state can create its standards; in this presentation, we will evaluate the
standards required by the Joint Commission and the state of Ohio.
, 2
SIMILARITIES
Joint
H&P Regulations State of Ohio
Commission
Must be created by a licensed physician X
Must contain a patient's chief complaint X X
Must have complete family and social history X X
H&P can be completed within 30 days prior to admission
X X
or registration
H&P is required for high-risk procedures, surgical
procedures, and any procedure that involves anesthesia X X
services
H&P is required for all inpatient admissions X
The Joint Commission (TJC) and the state of Ohio have very similar history and physical
documentation standards. TJC and the state of Ohio require that the history and physical
documentation be very detailed, including a chief complaint and a complete family and social
history. For both, a history and physical exam must be required for any high–risk procedures,
surgical procedures, and any procedures involving anesthesia services. Also, both standards
allow the history and physical to be completed up to 30 days in advance.
DIFFERENCES
Joint
H&P Regulations State of Ohio
Commission
Must be created by a licensed physician X
Must contain a patient's chief complaint X X
Must have complete family and social history X X
H&P can be completed within 30 days prior to admission
X X
or registration
H&P is required for high-risk procedures, surgical
procedures, and any procedure that involves anesthesia X X
services
H&P is required for all inpatient admissions X
The Joint Commission and the State of Ohio did not have many differences. The first difference
identified is that the Joint Commission requires a qualified physician or licensed practitioner to
be granted the privilege of creating the history and physicals (The Joint Commission, n.d.). The
state of Ohio not only lets qualified physicians or licensed practitioners create history and
physical documentation, but the medical staff and their designees can also document it (Ohfama,
