Health information refers to all of the data related to a person’s medical history, including symptoms, diagnoses, procedures, and outcomes. In the field of healthcare, such information is a strategic asset that can be used for organizational and medical decision making, performance improvement, cost management, and risk mitigation. Patient data requires high-level oversight in order to be used effectively and efficiently. In order to achieve its goals, an organization must be committed to an information governance program that underscores complete, current, and accurate information.
Health information management professionals use information governance to manage and control information, as well as support the activities of their organizations. It is often necessary to assess an organization’s existing policies and procedures to identify new areas of opportunity for information governance throughout the organization. Many information governance programs stem from HIM pain points, such as developing an enterprise-wide master patient index, or the need to improve health information exchange with other organizations. In an increasingly connected world, a healthcare organization must ensure that reliable patient information is available in the right place, at the right time, and to the right people. As health information is used in different ways by different people, HIM professionals must consider the professionals in a variety of roles who must be trained on information governance.
For your final project, you will assume the role of a health information manager for a newly formed hospital network. After reading the provided scenario about the hospital network and examining the provided sample patient records (Record One, Record Two, and Record Three), you will create a training manual on information governance for the medical coders and clinical professionals in the organization. The manual will discuss current data capture and distribution methods of the organization, regulations, and standards related to information governance and the organization’s current and future interoperability practices.
Imagine that you are the health information manager for the newly formed Quality Regional Healthcare LLC. The chief information officer (CIO) has tasked you with developing a training manual on information governance to provide guidance to the medical coders and clinical professionals of the new hospital organization. In the training manual, you will introduce the overall importance of information governance to this newly formed organization and explain the organization’s current data-capture and distribution techniques. You will provide examples of common documentation and classification mapping errors found in patient health records and discuss the implications of these errors. Finally, you will examine how the organization shares health information internally and externally and establish methods to improve interoperability and the successful execution of health information exchange (HIE) between hospitals.
B. Content and Documentation:
1. Describe content issues in the patient health records, using examples from the records to support your response. In other words, what required data elements are missing?
2. Describe documentation issues in the patient health records, using examples from the records to support your response. In other words, what information was documented incorrectly?
3. Explain the data management regulations and standards that are being violated as a result of the content and documentation issues in the records.
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