rebecca a. hulbert hi160 health information portfolio
TRANSCRIPT
Demographics
Name of practicum site: The Terraces at Skyline
Site Supervisor: Shawn RichardsType of Site: Long Term Care
Facility for ElderlyType of Ownership: Not for
Profit
Describe the health information department: The health
information department is on the 8th Floor. There is a locked
storage room where the closed charts and overflow filing
cabinets are kept.
The open patient charts are kept at the nurse’s station on the 7th
and 8th floor. How many employees work in the HI
Department? There is only one employee in the HI Department;
her name is Shawn Richards.
There is a fax machine located at the nurse’s station. There is a
photocopy room on the 5th floor. The site supervisor’s office is
located on the 8th floor; she has a computer with a printer in her
office. Communication is conducted via e-mail.
How many employees work in the HI Department? There is only
one employee in the HI Department; her name is Shawn
Richards.
Of these, how many are credentialed? Shawn Richards is
a credentialed as a Medical Assistant. She was working as a Medical Assistant and decided she would prefer working in
medical records.
The Medical Record
Process of admission is as follows: Information on the
resident is sent to Admission person, who gives it to a Nurse
to review and see if it is a resident they are able to take.
Then the information is sent to HI Department to enter in the computer (demographics, and then orders) a chart is made
(labels put on, labels on forms) etc....
Do you have a back up plan if the computer is down?
They have a web based computer system. If the computer is down
all records are on paper.
Computer is used for generating reports, and entering
demographics, but all work can be done without the computer
except for the billing and sending of MDS (Minimum Data Set) to
the State.
Then orders are sent from the hospital or wherever the resident is from and put in the computer
and verified by the doctor and the nurses and then put out for the
nurses and aides to document on
Storage and Retrieval The HI Department is responsible
for storage and retrieval. The records are filed alphabetically.
The record is first started on paper then entered into the
computer.
Re: the electronic information, what measures are in place to
assure the information is correct?It is only as accurate as the person entering it is. For
example if the aide writes down a weight incorrectly, it is then entered into the computer.
At that point it is incorrect. When the weight report is printed and reviewed the error or incorrect weight will be noticed and then
corrected.
How often are audits in the medical records done? Audits are done on a routine basis.
24hrs after admit to see that all paperwork was completed, and
then at regular intervals and special audits are done on an as
needed basis.
Scenario Question: Two patients named Ann Smith recently had blood work done. Ann Smith (DOB 3/3/28) had a CBC with differential done, but the results were filed on Ann Smith (DOB
7/15/38) electronic record. How would this error be corrected? Who would be responsible for
doing so?
** The HI or Medical Records Department or Shawn if it
happened at my internship site would be the one to correct it. It
would first be corrected by deleting the incorrect record in
the 2nd Ann smith. Then adding it to the correct record
How often is it audited for accuracy?
Which position is responsible for merging and unmerging patients
in the MPI? HI Department
Relationship between the HI Dept. and registration dept. (or receptionists) re: assigning of
medical record numbers?Most computer systems assign numbers for residents and alert you of names that are similar to avoid the Ann Smith scenario.
Is any technology in place that would aid in avoiding duplicate
patients?See above
Does the facility employ an
outside company to audit the MPI for accuracy?
No
Quantitative Analysis At what point is quantitative
analysis done? Shawn in the HI Department notifies the doctor of
any missing signatures.
The doctor is also responsible to filling out a discharge summary
for all residents.Shawn in Medical Records will
put any missing information needed in his box for signature
At this point is the analysis done in the electronic record or is it
printed?It is not done electronically
Is there a policy and procedure for analyzing records for
deficiencies? It is standard of practice when
closing a record to note any and all missing information.
In a skilled setting like she is in, it takes a couple of days for all the paperwork to get to me for
the final closing of a chart
Is it sufficient to satisfy both accreditation
standards and Conditions of Participation
regulations?The Terraces at Skyline just
had their State survey and the closed records passed the
survey process
What part of this function is most difficult?
The turnover is so quick and it is hard to get to the closed charts
because you are dealing with new charts and getting them ready.
Devise a form; which will be completed at the time of
quantitative analysis to tell physicians what is incomplete on the chart (know as a deficiency
sheet)
Scenario Question: **Based on your policies
and chart completion standards of the Joint
Commission: You are the director of health
information at Memorial Hospital. A Joint
Commission Survey is due in one year.
The CEO of the facility has asked that each
department send her a memorandum regarding areas of concern. Based on what you have seen, what would you write in
this memo? Be specific on which standard is not
being met.
MEMORANDUMTO: CEOFROM: Rebecca Hulbert,
Medical Records Department
DATE: July 13, 2010RE: Preparing for Joint
Commission survey that is due in one year
I have looked over the files in preparation for the Joint
Commission survey; which is due in one year. Everything seems to
be in order.
One area of concern would be that the admissions department
puts information in the computer before the resident is completely
admitted.
Because this is attached to the accounting it has become a
problem because some information stays in and is not corrected. I have requested that this part of admissions is only
completed when all the resident information is available.
Incomplete Chart Processing Once quantitative analysis is done, where does the chart go
from there?
How are the charts filed? (boxes for each physician, numerical
order, etc.)
Is this area of the department staffed by personnel who are
dedicated to this area?
At what point does an incomplete record become delinquent? 10
Days.
What kind of reporting is kept to notify administration of
delinquent charts?(She is not familiar with hospital
closing of records)
Release of Information Shawn in the HI Department is the
person who releases records.In a nursing home
environment the medical records department is usually the only person/dept. doing
ROI..
The Terraces at Skyline requires a written HIPPA approved form asking for
recordsThey can only release their records so not the hospital records that are received
when residents are admitted. Hospital records must be
requested from the hospital
Is there one or more employees devoted to the ROI functions? Shawn in Medical Records is
responsible for the ROI functions.
Is this person credentialed? She is a Medical Assistant.
Is an outside copy service used?Sometimes
How are subpoenas handled?Shawn in Medical Records would
be the person who handles any record related subpoenas.
Explain relationship this position has with the Risk Management/
and or Quality Assessment Departments?
Medical records works closely with these departments.
A call is placed to their legal department when records are
requested
Are there written policies that address ROI to requestors? How are walk-ins handled?
They require 48 hours to handle all requests and yes there is a
written policy
How are records, which are part of a lawsuit against a physician
or the hospital, handled?They must produce records if the
courts request them.
Electronic Functions Describe in detail, each of the functions within the
facility and which impact the HI department, which
are computerized?
For example: (Electronic Medical Record, dictation, transcription, MPI, chart
tracking, chart completion, electronic signature,
abstracting, etc.
As explained earlier, the computer in this setting is more
for reports and such. All transcription is done from a
paper copy and entered into the computer.
Cancer (tumor) registry: http://www.cdc.gov
/cancer/npcr/about.htm 1.The National Program of
Cancer Registries collects data on cancer patients. What type of data is collected? The type of
data collected is the occurrence of cancer; the type, extent, and location of the cancer; and the type of initial treatment.
1. Monitor cancer trends over time.
2. Determine cancer patterns in various populations.
3. Guide planning and evaluation of cancer control programs (i.e., determine whether prevention, screening, and treatment efforts
are making a difference).
4. Help set priorities for allocating health resources.
5. Advance clinical, epidemiologic, and health
services research.
6. Provide information for a national database of cancer
incidence.State cancer registries collect
data in order to help public health professionals understand how
cancer affects the nation.
http://apps.nccd.cdc.gov/uscs/ 1. What is the most recent year
for which data is available regarding the top 10 cancers in
the U.S.? 20062. In the U.S. in that year, what was the 10th ranked cancer for males (all races)? Pancreas
3. For male and females, what is the number 3 ranked cancer in the U.S.? Lung and Bronchus.4. In Los Angeles, for the same
time period, what is the number 1 ranked cancer for males and
females? Prostate5.From your answers to #3 and #4 – is there any significance to
this?
http://apps.nccd.cdc.gov/DCPC INCA/DCPC INCA.aspx
(I could not access this link exactly as it was so I had to
shorten it to access it)1. Look up your state’s statistics –what is your state’s ranking?
According to the interactive atlas for 2006: 482.1 out of 6,374,910.
2. Which state did not submit data for this time frame?
According to the interactive atlas for 2006, incident rates, all
cancer sites combined, male and female, all races there was more
than one: 1) Arizona, 2) Wisconsin.