Rebecca A. Hulbert

HI160 Health Information Portfolio

Demographics 

Name of practicum site: The Terraces at Skyline

Site Supervisor: Shawn RichardsType of Site: Long Term Care

Facility for ElderlyType of Ownership: Not for

Profit

Describe the health information department: The health

information department is on the 8th Floor. There is a locked

storage room where the closed charts and overflow filing

cabinets are kept.

The open patient charts are kept at the nurse’s station on the 7th

and 8th floor. How many employees work in the HI

Department? There is only one employee in the HI Department;

her name is Shawn Richards.

There is a fax machine located at the nurse’s station. There is a

photocopy room on the 5th floor. The site supervisor’s office is

located on the 8th floor; she has a computer with a printer in her

office. Communication is conducted via e-mail.

How many employees work in the HI Department? There is only

one employee in the HI Department; her name is Shawn

Richards.

Of these, how many are credentialed? Shawn Richards is

a credentialed as a Medical Assistant. She was working as a Medical Assistant and decided she would prefer working in

medical records.

The Medical Record 

Process of admission is as follows: Information on the

resident is sent to Admission person, who gives it to a Nurse

to review and see if it is a resident they are able to take.

Then the information is sent to HI Department to enter in the computer (demographics, and then orders) a chart is made

(labels put on, labels on forms) etc....

Do you have a back up plan if the computer is down?

They have a web based computer system. If the computer is down

all records are on paper.

Computer is used for generating reports, and entering

demographics, but all work can be done without the computer

except for the billing and sending of MDS (Minimum Data Set) to

the State.

Then orders are sent from the hospital or wherever the resident is from and put in the computer

and verified by the doctor and the nurses and then put out for the

nurses and aides to document on

Storage and Retrieval The HI Department is responsible

for storage and retrieval. The records are filed alphabetically.

The record is first started on paper then entered into the

computer.

Re: the electronic information, what measures are in place to

assure the information is correct?It is only as accurate as the person entering it is. For

example if the aide writes down a weight incorrectly, it is then entered into the computer.

At that point it is incorrect. When the weight report is printed and reviewed the error or incorrect weight will be noticed and then

corrected.

How often are audits in the medical records done? Audits are done on a routine basis.

24hrs after admit to see that all paperwork was completed, and

then at regular intervals and special audits are done on an as

needed basis.

Scenario Question: Two patients named Ann Smith recently had blood work done. Ann Smith (DOB 3/3/28) had a CBC with differential done, but the results were filed on Ann Smith (DOB

7/15/38) electronic record. How would this error be corrected? Who would be responsible for

doing so?

** The HI or Medical Records Department or Shawn if it

happened at my internship site would be the one to correct it. It

would first be corrected by deleting the incorrect record in

the 2nd Ann smith. Then adding it to the correct record

The Master Patient Index (MPI)Is it electronic?

Yes, paper MPI’s are not used in LTC anymore

How often is it audited for accuracy?

Which position is responsible for merging and unmerging patients

in the MPI? HI Department

Relationship between the HI Dept. and registration dept. (or receptionists) re: assigning of

medical record numbers?Most computer systems assign numbers for residents and alert you of names that are similar to avoid the Ann Smith scenario.

Is any technology in place that would aid in avoiding duplicate

patients?See above

Does the facility employ an

outside company to audit the MPI for accuracy?

No

Quantitative Analysis At what point is quantitative

analysis done?  Shawn in the HI Department notifies the doctor of

any missing signatures.

The doctor is also responsible to filling out a discharge summary

for all residents.Shawn in Medical Records will

put any missing information needed in his box for signature

At this point is the analysis done in the electronic record or is it

printed?It is not done electronically

 Is there a policy and procedure for analyzing records for

deficiencies? It is standard of practice when

closing a record to note any and all missing information.

In a skilled setting like she is in, it takes a couple of days for all the paperwork to get to me for

the final closing of a chart

Is it sufficient to satisfy both accreditation

standards and Conditions of Participation

regulations?The Terraces at Skyline just

had their State survey and the closed records passed the

survey process

What part of this function is most difficult?

The turnover is so quick and it is hard to get to the closed charts

because you are dealing with new charts and getting them ready.

Devise a form; which will be completed at the time of

quantitative analysis to tell physicians what is incomplete on the chart (know as a deficiency

sheet) 

Patient Name

Deficiency

Doctor Verified and completed

Scenario Question: **Based on your policies

and chart completion standards of the Joint

Commission:  You are the director of health

information at Memorial Hospital.  A Joint

Commission Survey is due in one year. 

The CEO of the facility has asked that each

department send her a memorandum regarding areas of concern.  Based on what you have seen, what would you write in

this memo?  Be specific on which standard is not

being met.

MEMORANDUMTO: CEOFROM: Rebecca Hulbert,

Medical Records Department

DATE: July 13, 2010RE: Preparing for Joint

Commission survey that is due in one year

I have looked over the files in preparation for the Joint

Commission survey; which is due in one year. Everything seems to

be in order.

One area of concern would be that the admissions department

puts information in the computer before the resident is completely

admitted.

Because this is attached to the accounting it has become a

problem because some information stays in and is not corrected. I have requested that this part of admissions is only

completed when all the resident information is available.

Incomplete Chart Processing Once quantitative analysis is done, where does the chart go

from there?

How are the charts filed? (boxes for each physician, numerical

order, etc.)

Is this area of the department staffed by personnel who are

dedicated to this area?

At what point does an incomplete record become delinquent? 10

Days.

What kind of reporting is kept to notify administration of

delinquent charts?(She is not familiar with hospital

closing of records)

Release of Information Shawn in the HI Department is the

person who releases records.In a nursing home

environment the medical records department is usually the only person/dept. doing

ROI..

The Terraces at Skyline requires a written HIPPA approved form asking for

recordsThey can only release their records so not the hospital records that are received

when residents are admitted. Hospital records must be

requested from the hospital

Is there one or more employees devoted to the ROI functions? Shawn in Medical Records is

responsible for the ROI functions.

Is this person credentialed? She is a Medical Assistant.

Is an outside copy service used?Sometimes

How are subpoenas handled?Shawn in Medical Records would

be the person who handles any record related subpoenas.

Explain relationship this position has with the Risk Management/

and or Quality Assessment Departments?

Medical records works closely with these departments.

A call is placed to their legal department when records are

requested

Are there written policies that address ROI to requestors? How are walk-ins handled?

They require 48 hours to handle all requests and yes there is a

written policy

How are records, which are part of a lawsuit against a physician

or the hospital, handled?They must produce records if the

courts request them.   

How often do employees receive continuing

education sessions re: HIPAA?

A minimum of yearly

Electronic Functions Describe in detail, each of the functions within the

facility and which impact the HI department, which

are computerized? 

What is the name of the Software? Answers on Demand.

For example: (Electronic Medical Record, dictation, transcription, MPI, chart

tracking, chart completion, electronic signature,

abstracting, etc.

As explained earlier, the computer in this setting is more

for reports and such. All transcription is done from a

paper copy and entered into the computer.

Cancer (tumor) registry: http://www.cdc.gov

/cancer/npcr/about.htm 1.The National Program of

Cancer Registries collects data on cancer patients. What type of data is collected? The type of

data collected is the occurrence of cancer; the type, extent, and location of the cancer; and the type of initial treatment.

2.Name and explain the six functions of state cancer

registries:

1. Monitor cancer trends over time.

2. Determine cancer patterns in various populations.

3. Guide planning and evaluation of cancer control programs (i.e., determine whether prevention, screening, and treatment efforts

are making a difference).

4. Help set priorities for allocating health resources.

5. Advance clinical, epidemiologic, and health

services research.

6. Provide information for a national database of cancer

incidence.State cancer registries collect

data in order to help public health professionals understand how

cancer affects the nation.

http://apps.nccd.cdc.gov/uscs/ 1.  What is the most recent year

for which data is available regarding the top 10 cancers in

the U.S.? 20062.  In the U.S. in that year, what was the 10th ranked cancer for males (all races)? Pancreas

3. For male and females, what is the number 3 ranked cancer in the U.S.? Lung and Bronchus.4. In Los Angeles, for the same

time period, what is the number 1 ranked cancer for males and

females? Prostate5.From your answers to #3 and #4 – is there any significance to

this?

http://apps.nccd.cdc.gov/DCPC INCA/DCPC INCA.aspx

(I could not access this link exactly as it was so I had to

shorten it to access it)1. Look up your state’s statistics –what is your state’s ranking?

According to the interactive atlas for 2006: 482.1 out of 6,374,910.

     

2. Which state did not submit data for this time frame?

According to the interactive atlas for 2006, incident rates, all

cancer sites combined, male and female, all races there was more

than one: 1) Arizona, 2) Wisconsin.

Summary: I had a really great experience.

Everyone was friendly, the location and building are

beautiful and it is a place I would like to end up when I am too old to take care of myself. I was able

to do coding and felt that I learned a lot and completed many

real life on the job projects.