Judy Jordan has just begun working as the health information manager in a large

Question

Judy Jordan has just begun working as the health information manager in a large physicians’ group practice. The patient’s name is the primary patient identifier and the records are filed alphabetically. Misfiles are a frequent problem, and in the large practice, patients sometimes have similar names. The records are not kept in a uniform format. Many of the doctors use an integrated format, but three of the physicians use the POMR. The practice wants to transition to an electronic health record. In reviewing the encounter forms, Judy finds codes that are no longer valid. She questions the staff and finds that no one can remember when the encounter form was updated. Bills frequently are returned for invalid codes. Electronic systems for patient registration and appointments have been implemented, but the staff also keeps a manual appointment log.

            A computer-generated list of appointments is given to the HIM clerk on the day prior to the appointments so the records can be pulled and available when the patients arrive. Many appointments that are entered in the manual log are not also entered in the electronic appointment system. The HIM clerk, therefore, spends extensive time each day pulling records for those appointments that are not on the computer-generated list. Judy has been asked to make suggestions for making the office run more smoothly.

1- What main problems should she identify?

2- Write a brief plan to solve ONEof the problems Judy identifies.

Explanation / Answer

1.A uniform to code must be devised so that confusion of maintaining the code does not crop up. Improper code must be prevented from occurring.

One other problem is the improper documentation of visits by physicians. This can lead to confusion when the patient visits the hospital in the future.

2. One of the ways to check improper documentation is by ensuring that each patient is given a unique patient id when he/she registers. The physician should then have to log the minutes of meeting in a register finally digitally signed by the patient to ensure that correct and relevant data is captured for a patient.

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