Manager Review of Health Record
Module 2 Objectives: After completing this module, you should be able to: 1. 2. 3. 4. Examine the role of documentation in healthcare service delivery. Distinguish between Continuity of Care (CC) and other types of care. Articulate how documentation drives patient safety and healthcare quality. Evaluate documentation to determine if it meets the stipulated standards and guidelines. Module 2 Readings • • • • • • • • • • • • The Purpose and Meaning of Medical Record Documentation (mednetcompliance.com) Medical Records Documentation Guidelines (martinspoint.org) Medical Records and Documentation Standards | Kaiser Permanente Washington Medical Records and the continuum of care | (mrpalsmy.com) What is a Continuity of Care Document (CCD)? – Definition from WhatIs.com (techtarget.com) Documentation: The Cornerstone of Patient Safety – OmniSure Your Medical Documentation Matters (cms.gov) What is the Continuum of Care and How Do You Get Started? – Cybernet Blog (cybernetman.com) Guidelines for Medical Record Documentation (ncqa.org) Documentation of information | Australian Commission on Safety and Quality in Health Care Set Forth the Basics of Good Medical Record Documentation – AAPC Knowledge Center The CCD: Continuity of Care Document Assignment The Continuity of Care Document (CCD) is an electronic document exchange standard for sharing patient summary information that includes the most needed pertinent information about the current and past patients’ health status. Analyze the 1) purpose of the CCD document, 2) its common components, 3) its role in patients’ safety and healthcare quality assurance (be specific), 4) the CCD-specific standard and its format. How does CCD differ from the CDA (Clinical Document Architecture) and C CDA (Consolidated Clinical Document Architecture)? Why? Your APA formatted document comprising 2-4, double-spaced pages, typed in 12-point Times New Roman excluding the Reference pages. Use minimum 2 credible sources to support your conclusions. Discussion As a health Information management (HIM) manager, you have been assigned to review a Physicians’ documentation for completeness of a patient’s health record in EHR. Which elements of the documentation would you look for in the health record and what is the rationale for your selection of these elements? How would incompleteness of the heal th record affect the quality of a patient’s health outcomes and Continuum of Care? How would the incompleteness of health records impact the revenue cycle of the practice? What measures would you recommend to minimize health record incompleteness in the future? Your initial post comprising a minimum of 250 words should be submitted by Saturday midnight, followed by a minimum of two (2) responses to classmates’ posts comprising at least 150 words supporting, challenging, clarifying, or adding to the existing information by Tuesday midnight. Build your argument using credible evidence. Please kindly provide response to the posts below. POST 1 It is essential for health information managers to review the records of a patient’s information through forms of ehealth such as EHR and EMR systems. Patient databases are always secured and provide privacy when patients view their diagnoses through the p atient portal. Additionally, physicians can secure patient’s information by keeping their health files sealed in a locked cabinet, signing out of their user accounts, and updating their passwords. EHR is an electronic health record system programmed to create real-time patient data to make information available to users and secure health information (HealthIT.gov, 2019). These health organizations include hospitals, nursing homes, small clinics, pharmacies, laboratories, and other assisted living facilities. There are a couple of elements in the documentation I would look for in a patient health record. I would search for vital encounter notes, insurance, billing, and immunization records. The rationale of these elements is Immunization records are essential to view because they give updated information on what vaccines or other forms of shots a provider gave to a patient. Vital encounters contain a patient’s weight, height, BMI, percentiles, blood pressure, pulse, and respiratory rate, which is beneficial in assessing a patient’s condition. Billing and insurance mainly help the staff and physician get paid, ensuring a patient’s insurance is eligible to use in the health organization. For example, if a facility does not accept MedStar, the practice will inform the patient beforehand before scheduling an appointment. The incompleteness of health records affects the quality of a patient’s outcome and the continuum of care in various ways. If patient forms are updated or are complete in the system, it can lead to significant errors such as misdiagnosis and poor treatments (360 Transcription, 2023). Additionally, the incompleteness of health records can impact the practice’s revenue cycle by causing the company thousands of dollars in debt. For example, billing can be affected by claim denials, risks to the safety of patients, and medical errors (360 Transcription, 20). The measures I would take to decrease the incompleteness of health records are to constantly update patient information, secure health information to prevent data disclosure, and plug inaccurate patient data entry. What is an electronic health record (EHR)? | HealthIT.gov. (2019, September 10). Retrieved from https://www.healthit.gov/faq/what-electronic-health-recordehr#:~:text=An%20electronic%20health%20record%20(EHR)% Transcription, 3. (2023, June 8). Incomplete medical records – Consequences and solutions. 360 Transcription. Retrieved from https://www.360transcription.com/incomplete-medicalrecords-and-solutions/#:~:text=For%20healthcare%20provide POST 2 Health Information Management (HIM) managers are crucial to healthcare management. HIM managers ensure accurate and complete patient health records, assuring patient care quality and efficacy. Assessing physicians’ Electronic Health Record (EHR) documentation for completeness is crucial to optimal healthcare delivery and data-driven decision-making. I would prioritize the chief complaint, history of illness, social history, mental assessment, diagnosis, and treatment plans. These factors are necessary for a complete patient assessment and informed medical decision-making (Kaiser Permanente Washington, n.d). They improve healthcare professional communication, reduce errors, track patient progress, and ensure billing accuracy. Focusing on these factors makes the health record a dependable source of information for high-quality care and healthcare revenue cycle integrity. Incomplete health records can harm patient health and treatment continuity. Without vital patient data, incomplete records can lead to missed diagnoses, inaccurate treatment decisions, and delays in care. Disjointed treatment plans and worsened patient situations might result from healthcare practitioners’ poor communication (Cybernet Manufacturing, 2023). Incomplete records also impair patient transitions across healthcare facilities, hindering the continuity of care. Furthermore, poor documentation also affects a medical practice’s revenue cycle. Coding errors, improper billing, and claim denials can delay or reduce reimbursement due to incomplete information. Accurate documentation is essential for correct coding, which impacts practice revenue (LeCompte, 2019). Inconsistent service documentation can lead to payer disputes, protracted reimbursement cycles, and lower income. Maintaining complete health records enables optimal patient care and protects the healthcare practice’s finances. In conclusion, I advocate standardized EHR templates and prompts to help healthcare practitioners consistently capture vital patient information to reduce health record incompleteness. Additionally, a Clinical Record Improvement (CDI) program with regular audits and comments helps improve record accuracy and completeness. These approaches will promote accurate and complete health records for better patient care and revenue cycle management. References Cybernet Manufacturing. (2023). What is Continuum of Care and How Do You Get Started? Cybernet Blog. https://www.cybernetman.com/blog/what-is-continuum-of-care/ Kaiser Permanente Washington. (n.d.). Medical Records and Documentation Standards. https://wa-provider.kaiserpermanente.org/provider-manual/working-withkp/records-standards LeCompte, J. (2019, March 14). The purpose and meaning of medical record documentation. Med-Net. https://www.mednetcompliance.com/purpose-medical-record-documentation/
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