The purpose of this first professional practice is to give you experience in health information management and for you to become familiar with how to adhere to government regulatory standards, accreditation guidelines, and quality improvement initiatives. Your participation in this professional practice experience enables you to apply many of the concepts of health informatics and information management that you have been studying. 

In this task, you will complete EHR Go activity questions that allow you to apply theory to practice. In addition, you will use your knowledge of health informatics and information management to explain how hospitals can ensure regulatory compliance and to describe the importance of basic skills, such as selecting the correct principal diagnosis and ensuring appropriate coder productivity. You will explain the importance of confidentiality and ethical behaviors as an independent health information professional. 

REQUIREMENTS

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc., unless specified in the task requirements. All other submissions must be file types that are uploaded and submitted as attachments (e.g., .docx, .pdf, .ppt).

A. Explain how different departments within a hospital could work both independently and collaboratively to ensure all elements of the “Record of Care, Treatment, and Services (RC)” standard from the Joint Commission quality improvement and accreditation standards are met.

 B. Explain why a patient’s medical record is considered an integral part of the Joint Commission’s tracer methodology for quality improvement and accreditation standards. 

 C. Discuss why the Centers for Medicare and Medicaid Services (CMS) utilize the Uniform Hospital Discharge Data Set (UHDDS).

 D. Explain why the selection of the correct principal diagnosis is critical, based on your knowledge of billing and reimbursement.  

E. Describe what a user would discover if searching for an ICD-10 code for “gastroesophageal” or “GERD” instead of for “gastro-esophageal,” including what this indicates about search protocol for ICD codes. 

 F. Discuss three strategies that could be used to maintain the average coding productivity in a department when a new coder is hired. 

 G. Discuss three potential challenges and three potential benefits to facilities managing recordcompletion policies by hiring physician liaisons or scribes to assist providers with documentation. 

 H. Explain the importance of professionalism, confidentiality, and ethical behavior relative to a stressful situation that you have been involved in or are aware of. Note: The stressful situation does not have to be technical in nature and could include any situation that occurred at work, at school, at a local business, or even nationally, such as the implementation of the Affordable Care Act exchange.

 I. Evaluate a healthcare organization’s communication strategy by doing the following: 

 1. Describe best practices for how a healthcare organization should communicate patient information with internal staff and healthcare providers. 

 2. Describe best practices for how a healthcare organization should communicate patient information with clinicians external to the organization. 

 J. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. 

 K. Demonstrate professional communication in the content and presentation of your submission.