MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

HIM Analyst Job Aid

Course, Program, and Institutional Outcome(s) Assessed:

This assignment measures your ability to meet the following outcome(s):

· Course outcome: Describe the process of ensuring data quality in an electronic health record environment

· Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards.

Relevant Background Information:

Ensuring quality information is an essential role of every health care employee. Coders understand the relationship of quality information and coding, but every health care employee needs to understand that relationship and what their role is in ensuring information collected is quality.

Assessment Purpose:

To demonstrate an understanding of the relationship between clinical documentation improvement and the electronic health record.

Assessment Directions:

Imagine you are the HIM Director at a hospital are creating the work flow for a new HIM 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 analyst to understand his/her role in ensuring quality data in the electronic health record (EHR).

Follow these steps to complete this assignment:

1. Read the following articles:

a. “Clinical Validation: The Next Level of CDI” by Debra Beisel Denton, RHIA, CCS, CCDS, et. al.

You can find this article as a PDF document in Blackboard.

b. “Medical Record Completion Guidelines” by McLaren Macomb found at this link:

http://www.mclaren.org/uploads/public/documents/macomb/documents/medical%20staff%20services/medicalrecordscompletion

You can access the article by pressing CTRL and clicking the left mouse or by copying and pasting the link into your web browser.

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.

4. Refer to the rubric at the end of this document. Check your work against the rubric to make sure you have done everything you’ve been asked to do.

5. Submit your work to your instructor by the designated due date.

MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

HIM Analyst Job Aid

Rubric

30-25.5

25.4-21

20.9-19.5

19.4-0

30-25.5

25.4-21

20.9-19.5

19.4-0

30-25.5

25.4-21

20.9-19.5

19.4-0