HIM 422 Module 3 Journal Example

Reviewed by Delia Ravenscroft, MSN, RN

This HIM 422 Module 3 Journal sample reflects on what a hospital's consent policy should require of the health record, prompted by an audit that found problems no signature could fix. It is written for SNHU HIM 422 (HIM-422), where BS Health Information Management journals connect law and ethics to the writer's own practice. The composite release of information supervisor at a 260-bed hospital in eastern Washington reviewed 60 surgical consent forms and found 14 with defects, including forms signed after sedation, missing dates and procedures described in terms patients would not understand. Using research that treats informed consent as a process of disclosure, capacity and voluntariness rather than a form, the journal considers what the record can prove, proposes policy changes such as teach-back documentation and admits the limits of paperwork.

CourseHIM 422 Ethical and Legal Considerations in Health Information Management
ModuleModule 3
Paper typeundergraduate reflective journal on consent documentation and record policy
LengthAbout 390 words, 3 pages
FormatAPA 7 student paper
SchoolSouthern New Hampshire University
ProgramBS Health Information Management
UpdatedSeptember 2026

Free sample paper for HIM 422 Module 3

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Module Three Journal

A Signature Is Not Understanding

This week our department audited 60 surgical consent forms from the past quarter as part of Tamarack Valley's record completion review. Fourteen had problems. Six were missing the date or time, which makes it impossible to show that consent came before the procedure. Five described the operation in terms such as "lap chole with IOC" that few patients would recognize. Three were signed after the patient had received sedation in the preoperative area. Every one of the 14 had a signature, and I realized that until now I had treated the signature as the thing that mattered.

What this page is doingThe journal opens with the audit findings that prompted reflection.
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The readings changed that view. Hall et al. (2012) describe informed consent as resting on disclosure of the relevant information, the patient's capacity to decide and the voluntariness of the choice, with the form serving only as evidence that this process took place. Grady (2015) argues that consent has drifted toward document management, focused on signatures and liability, while the harder task of making sure patients understand has lagged. A form signed after sedation fails on capacity no matter how complete it looks, and a form written in abbreviations fails on disclosure.

There is also evidence that understanding can be improved. Schenker et al. (2011) reviewed interventions for procedural consent and found that approaches asking patients to explain information back, along with extended discussion, improved comprehension more consistently than handing out written material alone. That gives health information management a role beyond collecting forms: the record can show whether the process happened.

What this page is doingThree sources reshape the writer's view of consent documentation.
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I am proposing three changes to our consent policy. Consent forms must state the procedure in plain words with the date and time of signing, and the preoperative checklist will stop cases where the consent time follows any sedation. Surgeons will document a brief teach-back, noting that the patient described the procedure, its main risks and alternatives in their own words. And interpreter use will be recorded on the form when the patient's preferred language is not English.

I am uneasy about one thing. A teach-back note can become another box to check, just as the signature did. Policy can require evidence, but only clinicians and patients can make consent real. What I can do is make sure the record asks the right questions and that our audits count understanding, not just ink.

What this page is doingThe writer proposes policy changes and reflects on their limits.
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References

Grady, C. (2015). Enduring and emerging challenges of informed consent. New England Journal of Medicine, 372(9), 855-862. https://doi.org/10.1056/NEJMra1411250

Hall, D. E., Prochazka, A. V., & Fink, A. S. (2012). Informed consent for clinical treatment. Canadian Medical Association Journal, 184(5), 533-540. https://doi.org/10.1503/cmaj.112120

Schenker, Y., Fernandez, A., Sudore, R., & Schillinger, D. (2011). Interventions to improve patient comprehension in informed consent for medical and surgical procedures: A systematic review. Medical Decision Making, 31(1), 151-173. https://doi.org/10.1177/0272989X10364247

What the HIM 422 Module 3 instructions ask for

The HIM 422 consent journal usually asks you to reflect on consent and health record policies, connecting legal requirements and ethics to your own experience or a realistic scenario. Journals are shorter and more personal than papers, so a response near 400 to 500 words that cites two or three sources in APA 7 fits most versions. Describe a concrete situation, explain what informed consent requires and what the record can and cannot prove, and consider the policies that govern consent documentation. Include your own reasoning and any discomfort or uncertainty, since journals reward honest reflection. Close with specific changes you would make or questions you still hold about how policy shapes practice.

How this HIM 422 Module 3 journal example is built

A review of 60 surgical consent forms at Tamarack Valley Medical Center finds 14 defects: missing dates or times, procedures written in abbreviations and three forms signed after sedation. Hall and colleagues frame consent as disclosure, capacity and voluntariness, Grady explains how consent drifted toward paperwork and Schenker and colleagues show that teach-back and extended discussion improve understanding. The writer proposes plain-language forms with times, a checklist stop for consent after sedation, documented teach-back and recorded interpreter use, then admits that any documentation requirement can turn into another box to check and commits to audits that measure understanding. The entry stays in the first person throughout.

Where the HIM 422 Module 3 rubric puts the points

Consent journals in HIM 422 are commonly assessed on thoughtful reflection, accurate explanation of informed consent and its documentation, connection to policy and practice, appropriate use of sources and clear writing. Entries that stand out move from a specific event to a changed understanding, rather than restating definitions. Graders value writers who distinguish legal documentation from the ethical process it is meant to prove and who propose changes grounded in evidence. An honest note about the limits of a proposed policy often earns more credit than confident claims, because the journal format rewards self-awareness as much as correct content. Specific numbers from a real or realistic review also help.

HIM 422 Module 3 help: the mistakes that cost points

Journal entries lose points when they summarize readings without personal reflection, confuse consent for treatment with authorization to release records or offer vague promises such as improving communication. Another frequent gap is ignoring capacity, language and minors. If your prompt focuses on a different record policy, such as amendments, retention or consent for photographs and recordings, send it with any course scenario so the reflection fits. Share whether your instructor wants first person. A custom journal can draw on your own workplace while following the same movement from event to insight, evidence, proposal and honest reflection used in this Tamarack Valley entry, and it can end with a question you still want answered by the end of the course.

Get HIM 422 Module 3 written to your instructions

Forward the HIM 422 Module 3 journal prompt and a short description of any consent situation you have seen. The entry will reflect on it honestly, explain what consent requires and what the record can prove, cite evidence and propose specific policy changes, returned within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.

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HIM 422 Module 3 questions, answered

Where can I find a free HIM 422 Module 3 Journal sample?

This page holds the whole HIM 422 Module 3 journal: a consent form audit, what the record must show and how policy can protect understanding.

What are the elements of informed consent?

Disclosure of relevant information, the patient's capacity to decide and a voluntary choice, with documentation serving as evidence of the process.

Why is a consent form signed after sedation a problem?

Sedation can impair capacity, so the signature may not reflect a valid decision regardless of how complete the form looks.

What is teach-back in informed consent?

Asking patients to explain the procedure, risks and alternatives in their own words to confirm understanding.

How is a journal different from a paper in HIM 422?

Journals are shorter and more personal, rewarding honest reflection on experience alongside accurate use of sources.