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1 page/≈275 words
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APA
Subject:
Health, Medicine, Nursing
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Essay
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English (U.S.)
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W7 reflection on medical record completion Health, Medicine Essay

Essay Instructions:

Imagine you are the HIM(health information management) Director at a hospital are creating the work flow for a new HIM(health information management) analyst position. You are creating a job aid to be used to help train this new employee.
The job aid will explain the documents within the electronic health record in regards to their importance to clinical documentation improvement (CDI). The goal of the job aid is for the new HIM(health information management) analyst to understand his/her role in ensuring quality data in the electronic health record (EHR).
2. Create a job aid that articulates the following three pieces of information:
a. Identify and explain the 10 most important documents in the EHR.
b. Discuss how each of the 10 documents is important to CDI.
c. Explain the role of the HIM Analyst in ensuring data quality in the EHR.
3. Determine a format that works best to share this information in the form of a job aid. Remember, a job aid should be a brief, well-organized document that provides easy access to reference information. Include the above information in your job aid.
use resources below:
1. a. “Clinical Validation: The Next Level of CDI” by Debra Beisel Denton, RHIA, CCS, CCDS, et. al.
http://docplayer(dot)net/125877541-Clinical-validation-the-next-level-of-cdi-january-2019-update.html
2. “Medical Record Completion Guidelines" by McLaren Macomb found at this link: http://www(dot)mclaren(dot)org/uploads/public/documents/macomb/documents/medical%20staff%20services/medicalrecordscompletion.pdf

Essay Sample Content Preview:

Health Information Management (HIM) Job Aid
Your Name
Subject and Section
Professor’s Name
Date
HIM JOB AID
This document presents the necessary information for the hospital’s Health Information Information (HIM) Analyst must know. This includes the protocols and rules including the (1) ten (10) important documents in the Electronic Health Records (EHR), (2) importance of these documents to the organization’s Clinical Documentation Improvement (CDI) Plan, and (3) your role in ensuring data quality.
To ensure the efficiency and quality of the hospital’s HIM compliance, kindly review this job aid prior to your first assignment.
Important Documents and their Roles
As an HIM analyst, it is our duty to ensure that the following documents are included in the records in compliance with the medical records standards. The following are the most important documents that we need as well as the reason why we need them.
1 FaceSheet
1 Increases the expedience of compiling, storing, and pulling up of personal demographic, financial, or social data.
2 Coding Summary
2 Allows the medical professional to understand the coding history of the patient in relation to ICD-10 and/or CPT-4 data.
3 Emergency Room Records
3 Improves CDI by compiling all the tests, diagnostics, and treatments that the patient underwent through during his time in the emergency room...
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