SECTION A
The manager of health information assesses the situation regarding the transition to electronic health records by researching what is involved in the transition from paper-based to the electronic records. To begin the data gathering project, you have scheduled a meeting with the HIM supervisors the next morning. After discussing the requirements from the HIM director, the supervisors tell you how they can use their expertise to assist with the project. They will give you the information in a few days.
Write 450 words that respond to the following questions with your thoughts, ideas, and comments. Be substantive and clear, and use examples to reinforce your ideas:
Step 1: Determine who uses the medical record.
- Who is authorized to make documentations in the medical record?
- Who reads the documentation?
- Who uses the documentation to compile data?
Step 2: Develop a list of the departmental forms found in the medical record and what purpose they have.
Step 3: While completing your research, you discover that the person making documentations in the medical record is not documenting specific data required by the inpatient coders who are reading the data.
- How can this be resolved?
- What could be suggested to authorized documentation users to provide more information to the coders?
SECTION B
The director of health information shares the agenda she was given by the CEO regarding what the basic needs are to begin the conversion project. As manager, you were put in charge of preparing this information for the director. You will compile considerable data regarding who uses the medical record and how it is used. You will need to prepare a report that will be used at a meeting with the CEO and administrative team.
Instructions
Step 1: Research the following information about the different users and functions of medical records in the hospital:
- Within the hospital, who uses the medical record and for what reason?
- What are the various functions of medical records?
- What medical record functions are performed in the HIM department? What functions will benefit from an electronic health record?
Step 2: Prepare a PowerPoint presentation that reflects the results of your research.
- This will consist of 7-10 slides.
- That does not include a title page or reference page.
- Data will be shown on a chart.
- Include speaker notes explaining each slide.
- The speaker notes should be 200 words or less.
SECTION C
Explain how the use of a speech recognition software program allows the data to be stored and retrieved, and how this relates to a Clinical Information System.
SECTION D
The information about the users and functions of hospital medical records has been delivered to administration. Now it is essential to look at the components of the medical record within the other entities operated by Small-town Health Center. The center owns and operates the following:
- A rehabilitation center where speech, physical, and occupational therapies are available for patients with strokes, joint replacements, and other types of injuries
- Manor Nursing Home, where long-term care is provided
- United Home Health, which provides home health services and maintains an office in the hospital
- Smalltown Physician Clinic, where patients receive primary care
Each of these facilities has its own paper-based medical records and has specific documentation requirements. All of these medical records will have to be converted to electronic health records. You will visit each facility to obtain the list of documents for each type of medical record.
Instructions
You will prepare a 700 words document minimum that will detail the various needs for documentation and a chart that will show which documents would be mutually used.
Step 1: The first page will have the following for the hospital, rehab center, nursing home, home health, and clinic:
- 1 paragraph for each facility that will explain briefly any special needs
- An explanation of why the documentation is needed.
Step 2: The second page will have a chart to show the list of the facilities with the required documents.
Step 3: What clinical information systems might be implemented that can be used by all entities?