7-3 Final Project Submission Paper: Training Exercise
7-3 Final Project Submission: Training Exercise
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For the final project, you are to imagine yourself as a new HIM professional at a hospital. You have been tasked with reviewing a series of records, as well as
Joint Commission Standards, to complete a training exercise. You will report on findings related to the hospital's compliance with laws, standards, and
regulations in regard to how health record documentation is collected, stored, and eventually reported.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final
submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
 Analyze health records for data components and use in professionally managing patient health
 Compile organization-wide health record documentation guidelines based on appropriate laws, standards, and regulations
 Analyze the utility of secondary data sources for the effective management of patient information
 Examine the use of technology for identifying effective data collection, storage, and reporting of health information options
Prompt
For the final project, you are to imagine yourself as a new HIM professional at New England North Hospital where you have been tasked with reviewing a series
of records (Record One, Record Two, Record Three), as well as Joint Commission Standards, to complete a training exercise. You will report on findings related to
the hospital's compliance committee with laws, standards, and regulations in regard to how health record documentation is collected, stored, and eventually
reported. In addition, you will analyze storage options for medical records and propose a recommendation for storage to enhance disaster recovery and data
security, and to assess performance of the computer systems. The exercise will serve as a useful tool for developing necessary HIM professional skills.
Note: Please make use of the Help button for the Joint Commission Standards, in the upper right on the main page. It includes PDFs and video tutorials to help
you navigate the E-dition.
To complete the project, you will utilize the information in the following scenario:
The New England North Hospital uses manual data entry for all clinical notes and vital signs. When a nurse or clinician enters the health record, he or she has to
manually enter the patient's medical record number from the patient's arm band. Workstations on wheels (WOW) are deployed to all clinical locations with
wireless communications to the main server, but the workstations need to be charged between uses and sometimes the nurse leaves the WOW plugged in in the
hallway, writes down vital signs for an inpatient, and charts the findings later. The healthcare information manager wants to automate some of the systems with
barcode readers, automatic data capture, and other tools to help reduce data entry errors.
The system has a data center in a power-conditioned, protected room in the hospital with generators to maintain power. The healthcare information manager is
concerned that a large disaster such as a fire, flood, or explosion could destroy the room with its server and all the data. There are several options to consider:
keeping a backup in another section of the hospital, keeping a backup in a remote location, or using a cloud server instead of the data center. Of course, a hybrid
system using two or more of these options could be used, and each system has its pros and cons.
Clinicians have been asking for internet access at the point of care of their patients to use for patient education or to search for standards of care for unusual
cases. At this time, the hospital network is completely separate from the internet to preserve security, but it seems it is time to allow access to the internet. It is
up to the hospital information manager to present a plan to bring the internet into the hospital while maintaining a high level of security.
Specifically, the following critical elements must be addressed:
I. Analysis of Health Record: To begin, you will perform an audit on selected medical health records to review and analyze, ensuring that the data required
for patient health management is complete. You will first review the records from the provided list.
A. Based on your review of the medical health records, analyze the contents for defining required patient health data elements:
i. Patient identification
ii. Past health issues
iii. Current health issues
B. Analyze the contents for completeness and accuracy in documenting individual events and encounters. Based on your analysis, define which
data elements are required for the following:
i. Recording patient's vital signs
ii. Recording health events
iii. Recording medication administration
II. JCAHO: In this section, you will review the Joint Commission Standards as they relate to the health record.
A. Identify the data JCAHO routinely reviews for compliance with information management systems.
B. Evaluate which records are complete and which have missing data.
C. Based on the missing data, outline the JCAHO standards where the hospital is deficient.
III. Secondary Data Sources: For this next section, you will examine the secondary data sources the hospital utilizes and report on your findings.
A. Explain how secondary data sources are created and how they are used to build local and national registries.
B. Identify which data elements in the database would be used to create the following:
i. A registry of patients admitted during a six-month time frame
ii. A cancer registry
IV. Systems and Technology: In this section, you will examine and report on what technology is being used and how it is being used within the organization.
A. Describe how the organization utilizes technology for collecting data, including the specific systems that are used.
B. Briefly summarize the type or types of storage the organization utilizes and the benefits of each.
C. Based on gaps or issues with functionality with the current systems in place, recommend types of technology and storage options that would
better serve the organization. Be sure to justify each recommendation.
V. Action Plan for Compliance: For the final section, you will compile your findings thus far, and make recommendations for the professional management
of patient health information within the organization.
A. Based on your audit of the medical health records, explain which data items are required for patient care and compliance with requirements.
B. Based on your identification of JCAHO requirements for information management standards and quality measures, report your findings on the
organization's compliance or noncompliance with such requirements.
C. Outline the compliance with both types of registries from the secondary sources and the importance of each.
D. Make recommendations for any identified compliance deficiencies and defend your recommendations.
Milestones
Milestone One: Analysis of Health Record and Joint Commission
In Module Three, you will submit the analysis of the Joint Commission Record of Care and the Treatment Service Standards, and compose a description of the
standards, importance of compliance, and the deficiencies. This milestone will be graded with the Milestone One Rubric.
Milestone Two: Systems and Technology
In Module Five, you will submit the analysis of the systems and technology of the organization, including the system for collecting data, the benefits of each
system, and your recommendations for systems that might fill any gaps. This milestone will be graded with the Milestone Two Rubric.
Final Submission: Training Exercise
In Module Seven, you will complete your secondary sources and action plan sections of your training exercise and submit your completed final project. It should
be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the
course. This submission will be graded with the Final Project Rubric.
Final Project Rubric
Guidelines for Submission: Your training exercise should be 6 to 8 pages in length (plus a cover page and references) and must be written in APA format. Use
double spacing, 12-point Times New Roman font, and one-inch margins. All references should be cited in APA format
FINAL PROJECT SUBMISSION: TRAINING EXERCISE
It is imperative to maintain high quality standards of service delivery in a hospital as a means of earning public confidence. The Joint Commission Standards sets up required standards for hospitals to meet in order to declare them efficient. These range from proper registry records, patient care, information system management, and data management. This report evaluates the service delivery at New England North Hospital to check whether it meets requisite standards.
Health records
Upon reception of a patient to the medical facility, physicians use several medical documents to capture patient information, in order to determine the best way of handling the patients. According to an audit done at the New England North Hospital, three main medical record forms were available for scrutiny: the history and physical form, immediate post-operative note and operative report (Stengel, Bauwens, Walter, Köpfer, & Ekkernkamp, 2004). These documents capture patient identification information such as name, age, occupation, contacts and place of residents among other useful information. The H&P captures patient medical history such as known allergies, genetic condition, disease common within the family, and current ailments. The information regarding medical condition regarding one of the family members can point to a certain disease condition. These forms also capture current health issues such as physiological changes, observable symptoms of the disease and the patient’s perspective of his/her own health.
Immediate post-operative note requires filling whenever a patient receives or requires a more specialized medical intervention or care such as surgery or intensive care unit. Therefore, there is recording of the name of the physician, pre-operative and post-operative diagnosis, and procedure performed, findings, estimated blood loss, and specimen removed, to assist in capturing well-informed patient information. After the procedure, the operative report should indicate the procedure, the complications developed by the patient and a note describing the procedure in detail. According to the audit done on the medical records, there were a lot of information missing from the main files, some nurses captured few patients’ information, failed to sign and date the documents, and only captured assumptive data from the patients. Additionally, many physicians failed to sign against the forms, proving hard to conduct a follow-up in case of misdiagnosis. Some of the records such as the H&P and postoperative report required filling within 24 hours of patient admission. However, it was evident that most nurses postponed the exercise and forgot it all together.
In addition, some of the documents failed in capturing patients’ vital signs such as recurrent symptoms, medical history, and physiological observations among others. The elements required for recording health events included family history, social factors, and patient’s statement. Prescription pads or drugs administered to patients also are inclusive of the H&P. The manual data capturing system coupled with non-reliance on internet connections, while using simple medical equipments added to the complexity of capturing data and therefore, unreliable information.
Joint Commission Standards regarding health records
According to the commission, the health records require filling within 24 after admission of a patient or upon recommendation for specialized services (JCMR, 2011). The commission highly emphasizes on date and time when taking down the information to ensure expedient care and intervention towards a medical condition. An H&P documentation that occurs 30 days prior to admission is untimely (JCMR, 2011). Additionally, the commission requires physicians to leave a comment and sign within each document. Most of the operative and post-operative files appeared fully filled, while most of the H&P files contained scanty information. The commission standards for effective information management system include security, processes, confidentiality, planning, and decision-making based on available information.
Secondary data sources
The creation of secondary data sources emanate from the routinely collection of data from hospital admissions and discharge records. This type of data is administrative data. Government census, research studies, and surveys may also act as invaluable sources of secondary data (Hox & Boeije, 2005). This can point to disease prevalence in a certain region, people; the susceptibility of certain people to contract a certain disease; a tested method of nursing care that proved successful; a new treatment procedure; or a new finding that requires attention. The medical practitioners may access this information from their databases or from the government registers. Administrative data are accumulation of long periods of data collection, and provide an important reference point to signify change (Hox & Boeije, 2005).
The US government has created several research institutions such as Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), and Food and Drug Administration (FDA) Health Services Research, to research, document and add these valuable research findings to private and public registries, which aim to promote good practice in their respective sectors. The registries may also include a conglomeration of hospital admissions and discharge data, collected in real time within a geographical region (Larsson, 2011). Example is the Maryland Medical Care Database (MCDB). These registries may employ an alphabetical order of diseases, and the patient who suffered from them. D...