Documentation for Specific Topics: Documentation Standards and Guidelines

Course overview

This course provides information about completion standards for hospital inpatient and outpatient health records. The course reviews record completion and documentation requirements included in the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) as published in the Code of Federal Regulations (CFR), and The Joint Commission (TJC) and Det Norske Veritas (DNV) accreditation standards. The course also addresses responsibilities in the record completion process. In addition, it describes unique factors that health professionals who are responsible for the completion of health records should be aware of to be compliant with hospital health record completion requirements. The goal of this course is to introduce certified professional coders, clinical documentation integrity specialists, and healthcare providers in hospital inpatient and outpatient settings to the documentation standards and guidelines for documenting complete and compliant healthcare encounters.