4.4 Policies and Procedures for Information Governance

Policy turns governance into repeatable work

AHIMA's current RHIA Domain 1 includes policies and procedures for record data, documentation management, and information governance. This means the exam expects more than general awareness. The RHIA should be able to recognize when a risk is caused by missing policy, outdated procedure, unclear ownership, weak monitoring, or informal practice that varies by department.

A policy states the organization's rule, expectation, scope, authority, and rationale. A procedure describes the step-by-step method for carrying out the policy. For example, a correction policy may state that inaccurate record entries must be corrected transparently with audit trail preservation. The procedure may describe who reviews the request, how the EHR function is used, what notice is documented, and how the corrected record is flagged or communicated.

What good information governance policy includes

A good policy names the information asset, affected roles, governing requirements, owner, definitions, workflow expectations, documentation requirements, exceptions, enforcement method, review cycle, and escalation path. It should be practical enough to guide staff behavior. A policy that is too vague to apply will not support consistent decisions. A procedure that contradicts system workflow will create workarounds.

Policy should also match current operations. If the organization adds a new EHR module, patient portal function, data warehouse feed, or scanning workflow, related policies may need review. If a regulation, accreditation requirement, contract, or reporting specification changes, governance documents may need revision. The RHIA should not wait for audit failure to discover that procedures no longer match practice.

Policy evaluation checklist

• Does the policy name its scope and information asset clearly?
• Are key terms defined consistently with the data dictionary or record policy?
• Is ownership assigned to a role or committee?
• Are staff responsibilities and handoffs clear?
• Does the procedure match the actual system workflow?
• Are exceptions, corrections, and escalations defined?
• Is monitoring required and tied to a measurable standard?
• Is there a review date and approval authority?

In exam scenarios, a repeated inconsistency often signals a policy or procedure gap. If departments destroy documents differently, use different data definitions, correct records through informal notes, or apply retention rules inconsistently, the answer should move toward standardized policy, training, auditing, and governance oversight. A one-time reminder may help communication, but it does not create a controlled process.

Connecting policy to culture

Policies work only when they are understood and enforced. Staff need training that explains the reason behind the rule and the steps to follow. Managers need metrics to know whether the process is working. Governance committees need authority to resolve conflicts between convenience and record integrity. The RHIA leader helps convert information governance from a document library into daily practice.

For study, read policy scenarios by asking what rule should exist, who owns it, how staff carry it out, and how the organization proves compliance. The best answer usually creates clarity and accountability.