Sayles n b and l gordon 2016 health information

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Sayles, N. B. and L. Gordon. 2016. Health Information Management Technology: An Applied Approach , 5th ed. Chicago: AHIMA.
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Copyright ©2017 by the American Health Information Management Association. All rights reserved. 235 5.8 Tracer methodology Subdomain V.A.2 Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification Subdomain VI.F.1 Identify departmental and organizational survey readiness for accreditation, licensing, and/or certification processes Consider the role that health information management has on preparation for tracer methodology surveys. Determine at least three ways that HIM can assist in tracer preparation. Answer Health information management will be asked to supply the records of patients that will be included in the tracer activity. Documentation practices will be scrutinized and therefore, periodic, on-going, record review will help identify areas for improvement. This will include adherence to the do-not-use abbreviation list. Legibility is another important factor. Participation in mock tracers will identify areas for improvement. Using results of periodic record reviews will enable HIM to connect with specific departments and physicians to promote better documentation, and thereby enhance patient safety and quality of care. (Shaw and Carter 2015, 412–417; HCPro 2004) References HcPro. 2004 (January). HIM-HIPAA Insider . Preparing for Tracer Methodology. . com/HIM-37036-865/Preparing-for-Tracer-Methodology.html Shaw, P. L. and D. Carter. 2015. Quality and Performance Improvement in Healthcare, A Tool for Programmed Learning, 6th ed. Chicago: AHIMA.
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236 Copyright ©2017 by the American Health Information Management Association. All rights reserved. 5.9 Delinquent medical records Subdomain V.A.2 Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification When you came on board as HIM director, an issue needing immediate attention was the high delinquency rate of medical record completion. In fact, at the last The Joint Commission survey, the organization received a zero (0) for insufficient compliance with this standard. The organization’s current practice is that a letter is sent to physicians once charts have become delinquent at 30 days post-discharge. Follow-up letters continue weekly, and if charts weren’t completed, the previous director would call the physician office. Strategize solutions to the high delinquency rate. 1. Recommend a minimum of four options that could be implemented easily and have a positive impact on the record completion process. 2. Note three options that will take longer to implement and assess the pros and cons of implementing those options. Answer Easy options include: Sending letters at the 15-day mark (prior to delinquency) Clean, organized area for completion Courteous, helpful staff Provide beverages and snacks in the completion area Establish a physician schedule or have them call ahead for charts (paper completion)
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