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Healthcare Assignment on None Acute Health care research assignment

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Healthcare Assignment on None Acute Health care research assignment

Format of the Report

(Use the headings as noted below and repeat the questions in your report.)

The format of the report shall be:

Introduction: (Write a paragraph introducing the healthcare site you visited and the person you interviewed.)

Facility/Site General Information:

What type of non-acute healthcare setting are/did you visiting?

Pre-interview research and sources:

Interview information:

What is the mission/vision statement for the healthcare organization?

Pre-interview research and sources:

Interview information:

Is the facility an outpatient, inpatient, both inpatient and outpatient or another type of facility?

Pre-interview research and sources:

Interview information

What types of services are provided at the department/facility?

Pre-interview research and sources:

Interview information

What term is used to refer to patients treated/serviced by the facility?  (e.g., patients, clients, residents, etc.)

Pre-interview research and sources:

Interview information:

How does the facility/site quantify their services? Think of this question in terms of the type of setting. (e.g. # of visits per day, number of beds/occupancy rate, # admissions, # discharges, etc.) 

Pre-interview research and sources:

Interview information

 

Regulatory/Accreditation

Is the facility licensed?  If yes, by whom?

Pre-interview research and sources:

Interview information

Is the facility accredited? If yes, by whom?

Pre-interview research and sources:

Interview information

Are there other regulatory agencies/organization that impact the facility’s services or operations?

Pre-interview research and sources:

Interview information

Doesthe facility undergo any type of survey by licensing/accrediting organizations? If yes, when was their last survey?

Pre-interview research and sources:

Interview information

Health Records 

Does the facility have an EHR, hybrid or paper-based record?

Pre-interview research and sources:

Interview information

If there is an EHR, who is the vender?  If the site has a hybrid record, what aspects of the health record is maintained on paper? What aspects of the health record are part of the EHR?

Pre-interview research and sources:

Interview information

Who documents in the health record and what type of documentation do they enter into the record? (e.g. nurses, physicians, laboratory technicians, physical therapists, etc.)

Pre-interview research and sources:

Interview information

Ask to review a de-identified (demo) health record.

Obtain samples of health record forms if possible.

Pre-interview research and sources:

Interview information

How is health record documentation that is not generated by the site entered into the health record?  (e.g., x-ray results, laboratory results, other diagnostic results, transcribed reports, referral letters, etc.)

Pre-interview research and sources:

Interview information

Is barcoding used by the site/department?

Pre-interview research and sources:

Interview information

What functions of an EHR are used by the facility or site? (e.g, e-prescribing, patient portals, clinical decision support, results reporting, etc.)

Pre-interview research and sources:

Interview information

Isdocumentation captured at the point of care (i.e. at the time the service is rendered?

Pre-interview research and sources:

Interview information

If an EHR is used, what stage of meaningful use has been reached?

Pre-interview research and sources:

Interview information

Are electronic signatures used at the site/department?

Pre-interview research and sources:

Interview information

Who is responsible for maintenance of and updates to the electronic health record?

Pre-interview research and sources:

Interview information

What person/department is responsible for monitoring the quality of documentation and the completion of the health record?

Pre-interview research and sources:

Interview information

How are chart deficiencies “tagged”  in the health record?

Pre-interview research and sources:

Interview information

How is access to the health record monitored and controlled?

Pre-interview research and sources: 

Interview information

Are there any credentialed HIM professionals working at the site/in the department?  (RHIT, RHIA, CCS, CCS-P, CPC, etc.)

Interview information

Release of Information

Who is responsible for processing requests for health records?

Pre-interview research and sources:

Interview information

What type of request requires an authorization signed by the patient?

Pre-interview research and sources:

Interview information

What is the turnaround time for completing requests?

Pre-interview research and sources:

Interview information

What types of requests for information are received by the department/facility?

Pre-interview research and sources:

Interview information

Is there a charge for health records copied in response to a request for records?

Pre-interview research and sources:

Interview information

Who assures HIPAA compliance at the facility/department/site?

Pre-interview research and sources:

Interview information

Coding/Reimbursement

What medical coding system(s) is/are used by the site? (e.g., ICD-10-CM, ICD-10-PCS, CPT, SNOMED)

Pre-interview research and sources:

Interview information

What type of reimbursement methodology is used to reimburse for services provided in the type of setting?  (e.g. RBRVS, DRGs, APCs, RUGS, fee-for-service)

Pre-interview research and sources:

Interview information

Who assigned medical codes at the site?

Pre-interview research and sources:

Interview information

Is there a computer software used to assist with code assignment or is coding done by using the appropriate coding book(s)?

Pre-interview research and sources:

Interview information

Master Patient Index (MPI)/Unique Patient Identifier

What information system serves as the master patient index (MPI)?

(e.g. admission/discharge/transfer system (ADT), scheduling/registration systems, manual hard copy index file or report, etc.)

Pre-interview research and sources:

Interview information

Does the site assign a number unique to an individual patient’s health record and/or an episode of care?   What do they call this number?

 Pre-interview research and sources:

Interview information

When errors are found in the MPI, who is responsible for correcting the errors?

Pre-interview research and sources:

Interview information

Compare and Contrast:

How closely did your pre-interview research information compare to the information you gathered from the site? (Specifically, state aspects of the research that differed from what you found out during the interview. Be specific.)

Conclusion: (Write the conclusion.) Address your answers to the following questions in your conclusion.

What makes this facility/department unique as compared to other non-acute healthcare settings?

What aspect of the site you visited did you like the most?   What aspect did you like the least?

Is this type of setting a place you would like to work? Why or Why not?

 

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