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WGU C803 Task 4: HEALTH RECORDS DOCUMENTATION AND STORAGE | 2025
Latest Update with complete solutions.
HEALTH RECORDS DOCUMENTATION AND STORAGE
College of Health Professions, Western Governors University
Bridgette Stasher-Booker
15 March 2025
, 2
HEALTH RECORDS DOCUMENTATION AND STORAGE
SIMILARITIES
History and physical examinations between the state of Arkansas and The Joint
Commission are similar in many ways. They include being completed within 30 days with a
couple of stipulations. Entries must be recorded, dated, and signed for both Arkansas and TJC.
The following items must be included in the H&P for TJC and Arkansas: chief complaint, past
medical history including family, physical examination, and identifying data. All documentation
must be recorded prior to surgery. Both require that updates be documented 24 hours prior to
surgery.
DIFFERENCES
The differences include what is required for history and physical examinations when
completed up to 30 days prior. When it comes to Arkansas, the examination is updated at the
time of admission, and the H&P must be authenticated by the attending or treating physician
(Westlaw, n.d.). The stipulations for the Joint Commission are that the physician includes an
update note that is attached to the H&P and must be included within 24 hours of admission
(WGU, n.d.). Another difference is when the H&P shall be in the patient’s medical record. In
Arkansas, it is 48 hours prior to admission (Westlaw, n.d.). The Joint Commission is within 24
hours after admission but before surgery (WGU, n.d.).
JUSTIFICATION
It is important to include social and personal history documentation in EHR because this
information can help get to the root cause of the patient’s chief complaint. Some factors to
WGU C803 Task 4: HEALTH RECORDS DOCUMENTATION AND STORAGE | 2025
Latest Update with complete solutions.
HEALTH RECORDS DOCUMENTATION AND STORAGE
College of Health Professions, Western Governors University
Bridgette Stasher-Booker
15 March 2025
, 2
HEALTH RECORDS DOCUMENTATION AND STORAGE
SIMILARITIES
History and physical examinations between the state of Arkansas and The Joint
Commission are similar in many ways. They include being completed within 30 days with a
couple of stipulations. Entries must be recorded, dated, and signed for both Arkansas and TJC.
The following items must be included in the H&P for TJC and Arkansas: chief complaint, past
medical history including family, physical examination, and identifying data. All documentation
must be recorded prior to surgery. Both require that updates be documented 24 hours prior to
surgery.
DIFFERENCES
The differences include what is required for history and physical examinations when
completed up to 30 days prior. When it comes to Arkansas, the examination is updated at the
time of admission, and the H&P must be authenticated by the attending or treating physician
(Westlaw, n.d.). The stipulations for the Joint Commission are that the physician includes an
update note that is attached to the H&P and must be included within 24 hours of admission
(WGU, n.d.). Another difference is when the H&P shall be in the patient’s medical record. In
Arkansas, it is 48 hours prior to admission (Westlaw, n.d.). The Joint Commission is within 24
hours after admission but before surgery (WGU, n.d.).
JUSTIFICATION
It is important to include social and personal history documentation in EHR because this
information can help get to the root cause of the patient’s chief complaint. Some factors to
