Policy Manual sample

MDT Home Health Care Agency, Inc. STANDARDIZED TERMINOLOGY, DEFINITIONS, ABBREVIATIONS, ACRONYMS, SYMBOLS POLICY It is the Agency policy to effectively manage the collection of health information that comes from multiple sources. Our Agency shall collect information in standardized formats and terminology to ensure data integrity and reliability, as well as increased ease of use by organizational staff. Capturing accurate data in standardized language will help clarify information that is used by different staff members for various purposes and help the organization rely on that data for reimbursement, risk management, performance improvement (QAPI) and infection surveillance. PROCEDURE 1. The Board of Director, QAPI committee of the Agency shall approve all administrative and clinical forms for use by staff to document treatment, care and services. 2. Our Agency shall use uniform data sets to standardize data collection throughout the organization. a. Each page of all clinical and administrative forms shall minimally include the client’s name and medical record number. b. The same data fields that exist on different forms will be similarly labeled. c. Forms may include other client identifying information based on the purpose of the form’s use, e.g., Date of Birth, Date of Admission, and Date of Discharge. d. When appropriate, forms used to collect clinical information shall include data fields for identifying the source(s) of the information. e. All forms shall be uniquely numbered and contain the date the form was approved and/or last revised. 3. Our Agency shall use standardized terminology, definitions, abbreviations, acronyms, symbols and dose designations when forms are designed and when staff document the provision of care, treatment and services in the medical record. a. Staff shall use only symbols and abbreviations included on the “Approved Symbols and Abbreviations List” approved by the Clinical Department. (See list Policy). b. Staff shall not use symbols and abbreviations included on the “Not Approved Symbols and Abbreviations List” approved by the Clinical Department. (See list Policy). c. Our Agency leaders and supervisors shall communicate to all staff members the Approved and Not Approved Symbols and Abbreviations Lists. d. During a medical records audit, if non-approved abbreviations, acronyms, symbols or dose designations are found in Our Agency staff documentation, the Medical Records Clerk or administrative support staff shall notify the supervisor of the staff member responsible for completion of the clinical or administrative documentation. The documentation shall be promptly corrected and given to administrative support staff for filing in the record. 4. Staff members who wish to use symbols and abbreviations, acronyms, and dose designations not on the Approved or Not Approved Symbols and Abbreviations Lists shall request approval from leadership before seeking to have either list modified. Upon approval by leadership, this policy shall be reviewed by Clinical and QAPI department for consideration and approval of changes to either list. 5. The list of approved symbols and abbreviations shall be minimally reviewed on an annual basis. Home Health Agency Policies A-168