Health Information Management

Documentation Compliance Plan

HIM Connection, November 3, 2009

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In addition to policies and procedures, HIPAA has provisions related to documentation. These require that documentation of all of the following be retained in either paper or electronic form:
  • Actions—If a standard requires that an action be in writing, the written request, denials, response, or other action must be retained.
  • Activities—If a standard requires documented evidence of policies and procedures, training, or other activities, the evidence must be retained.
  • Assessments—The security rule requires a risk analysis and ongoing assessments and evaluations.
  • Representations—The privacy rule permits some oral representations (e.g., with respect to conduct of preparatory research, public health authority for access), but if representations are performed in writing, requested to be in writing through policy, or require a check of credentials, this documentation must be retained.
  • Designations—Organizational relationships must be designated, and this must be retained.
 
Note: This information is fromthe Guide to HIPAA Auditing, Second Edition, by Margret Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS. For ordering information, visit the HCMarketplace or call 887-727-1728.



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