Create a total of two (2) policies to address electronic health record documentation and traditional paper-based health record documentation.

Policy 1: Electronic Health Record Documentation

• All healthcare providers within the organization are required to document patient information using the organization’s electronic health record (EHR) system.
• All patient encounters, including but not limited to office visits, hospital admissions, and procedures, must be documented in the EHR within 24 hours of the encounter.
• Providers are responsible for ensuring that all documentation is accurate, complete, and legible.
• Providers must also ensure that all patient information is kept confidential and in compliance with HIPAA regulations.
• Providers who fail to comply with these EHR documentation policies may face disciplinary action.

Policy 2: Traditional Paper-Based Health Record Documentation

• In the event that the EHR system is unavailable or electronic documentation is not possible, healthcare providers may document patient information on paper.
• These paper records must be scanned and uploaded into the EHR system within 24 hours of the encounter.
• Providers are responsible for ensuring that all documentation is accurate, complete, and legible.
• Providers must also ensure that all patient information is kept confidential and in compliance with HIPAA regulations.
• Providers who fail to comply with these paper-based documentation policies may face disciplinary action.