Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress clinical findings and discharge status.

Healthcare Regulations




This Competency Assessment (CA) assesses your level of performance on the specific outcome(s) that are the focus of this course. The CA requires you to demonstrate your knowledge understanding and proficiency of the outcome(s). Be sure to use the other activities in this course prior to attempting the CA. You can attempt the CA an unlimited number of times within the term. However the CA must be completed successfully by the end of the term to earn credit.

Be sure to review the Competency Assessment Checklist Rubric in order to understand the criteria on which you will be evaluated.

Instructors will provide feedback on the CA. If you expect to receive feedback revise and resubmit this CA near the end of the term you will need to make your submission no later than 5 days before the end of the term.

Please refer to your syllabus for additional Competency Assessment requirements.

The end-of-course survey is your opportunity to provide us with valuable feedback about your experience as a learner the course materials and your instructor. The survey takes approximately five minutes to complete. We take your feedback very seriously. Instructions

Imagine that you are an administrator for a large hospital. You have been tasked with compliance for the facility. Demonstrate competence in healthcare law and ethics by following the instructions below in completion of this multi-part assignment.


Competency Assessed



Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress clinical findings and discharge status.

A 45-year-old female has requested a copy of her 80-year-old father’s health record. She has presented POA and has a legal right to access his records. You provide a copy to the woman but she has many questions regarding documentation of her father’s diagnosis. He was admitted to the ICU last week from the skilled nursing facility. When discharged he was transferred to an LTACH. In a brief written response to the woman relate the components of the health record that supports diagnosis and reflects the patient’s progress clinical findings and discharge status. Explain the documentation used for these purposes within skilled nursing facilities ICU and LTACH.


Identify laws and regulations applicable to health care.

Imagine that you are the Director of Health Information at a hospital and you have been asked to create a “one-page” pamphlet on the major laws and regulations guiding health record retention and destruction. Draft an outline summarizing a total of five (5) best practices in a retention/destruction program. In addition to your text you may refer to The Joint Commission (TJC) State law(s) (pick any state) and Centers for Medicare and Medicaid Services (CMS).


Analyze legal concepts and principles to the practice of HIM.

A hacker has penetrated the network of the business associate who provides cloud-based storage for the hospital. All patient records within the last two months were compromised. As HIM Director you have been tasked with organizing a response to this breach. Differentiate the steps related to breach notification.


Evaluate policies and strategies to achieve data integrity.

A patient has requested an amendment to their medical record and the provider does not agree with the amendment language the patient wants. Recommend via policy how you would ensure data integrity and quality of health information exchange.


Recommend compliance of health record content across the health system.

Imagine you are the Manager of a Health Information Management Department. The Board of Directors has tasked you with evaluating and interpreting the Joint Commission standards regarding documentation and develop a recommendation on how the facility can ensure compliance with documentation standards.

This Assessment should be a Microsoft Word (minimum 1500 words) document in addition to the title and reference pages.

Minimum Submission Requirements

Your paper must be written in Standard English and demonstrate exceptional content organization style and grammar and mechanics.
Your writing should be well ordered logical and unified as well as original and insightful.
A separate page at the end of your paper should contain a list of references in APA format. Use your textbook the Library and the internet for research.
Be sure to cite both in-text and reference list citations where appropriate and reference all sources. Your sources and content should follow proper APA citation style. Review the APA formatting and citation style found in the Writing Center. The Writing Center can be found within the Academic Support Center under Academic Tools in the left navigation of your course. (It should include a cover sheet paper is double spaced in Times New Roman 12-point font correct citations Standard English with no spelling or punctuation errors and correct references at the bottom of the last page.)
If work submitted for this competency assessment does not meet the minimum submission requirements it will be returned without being scored.


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