Health care organization must have in place policies on the documentation requirements for the entire health record. HIM professionals are responsible for ensuring that the requirements are followed so that the healthcare facility is in compliance with the state and federal laws, accreditation and the Medicare Conditions of Participation (CoP). One vital piece of clinical data in the medical record is the history and physical report. It is imperative that the healthcare facility establishes and follows documentation and completion guidelines for the H&P. For this portion of the policy manual you are required to assess the Documentation Requirements for a health information documentation policy with a focus on the history and physical portion of the policy as an example. Developing the policy that relates to the documentation in a history and physical will allow you to evaluate the requirements of the policy that would encompass the entire record.