4.4 Policies and Procedures for Information Governance

Policy turns governance into repeatable work

AHIMA's RHIA Domain 2, Data and Information Governance, includes policies and procedures for record data, documentation management, and information governance. The exam expects more than general awareness. The RHIA should recognize when a risk is caused by a missing policy, an outdated procedure, unclear ownership, weak monitoring, or an informal practice that varies by department. AHIMA frames this through its Information Governance (IG) principles, often summarized as accountability, transparency, integrity, protection, compliance, availability, retention, and disposition.

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

Note the legal distinction the exam tests: a clinician makes a correction/amendment; under HIPAA, a patient may request an amendment, which the provider can grant or deny with a documented process, never an erasure of the original entry.

What good information governance policy includes

A strong policy names the information asset, affected roles, governing requirements, the owner, key definitions, workflow expectations, documentation requirements, exceptions, the enforcement method, a review cycle, and an escalation path. It must be practical enough to guide behavior. A policy too vague to apply cannot drive consistent decisions, and a procedure that contradicts the actual system workflow guarantees workarounds.

Policy must also track current operations. When the organization adds an EHR module, a patient-portal function, a data-warehouse feed, or a scanning workflow, related policies need review. When a regulation, accreditation requirement, payer contract, or reporting specification changes, governance documents need revision. The RHIA should not wait for an audit failure to discover that procedures no longer match practice; a defined review cycle (often annual, or sooner when triggered) is the control.

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 named 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 an approval authority?

In exam scenarios, a repeated inconsistency usually signals a policy or procedure gap. If departments destroy documents differently, use different data definitions, correct records through informal sticky notes, or apply retention rules inconsistently, the answer should move toward a standardized policy, training, auditing, and governance oversight. A one-time email reminder may improve communication, but it does not create a controlled, defensible 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 converts information governance from a document library into daily practice. For study, read each policy scenario by asking: what rule should exist, who owns it, how do staff carry it out, and how does the organization prove compliance?

The best answer almost always creates clarity, accountability, and a way to monitor adherence.

Where governance authority lives

Policies must name an owner, and on the exam that owner is usually a role or committee, not a single individual acting informally. Many organizations run a data/information governance committee or council that approves enterprise definitions, retention schedules, and access policies, with HIM, compliance, privacy, security, informatics, quality, and clinical leadership represented. A health record committee (or medical records committee) typically governs record content, completion rules, and forms or template approval.

Distinguishing these bodies helps you pick the answer that routes a decision to the correct authority rather than to an ad hoc fix.

Information governance versus data governance

AHIMA draws a useful distinction the exam may test. Information governance is the broad, enterprise framework for the accountability, policies, and decision rights over information as a strategic asset across its full lifecycle. Data governance is the narrower discipline focused on the data itself, definitions, quality, lineage, and stewardship, that supports the larger framework. A data dictionary is a data-governance tool; a retention schedule and a privacy policy are information-governance instruments.

When a scenario describes enterprise-wide accountability and strategy, lean toward information governance; when it describes element definitions and data quality, lean toward data governance.

A short worked example

Three clinics correct erroneous entries differently: one writes over the original note, one adds a sticky note, one uses the EHR addendum tool. The governed response is not a one-time email. It is a single correction policy stating that originals are never erased and the audit trail is preserved, a procedure that specifies the EHR addendum/amendment workflow, training on why integrity matters, and a periodic audit sampling corrections for compliance, with findings escalated to the records committee.