PPE - Essay Example

Report on Chart Deficiency, Chart Quality, Chart Disposal and Coding in a Health Information System. of Affiliation: In any clinical setting, it is important to monitor and document the physiological observations which is the main component of the both the recognition and response systems (Garber, Gross, & Slonim, 2010). This report was on a clinical site that specializes on orthopaedic and spinal care, physical therapy and the management of inpatient pain. According to Garber, Gross, & Slonim (2010) a chart on observation and response was used to record inpatient observations and specified the actions that were to be taken in case of deteriorating conditions or pain.
It was observed that manual management of chart analysis slows down the physician and health information team’s productivity, negatively affecting the billing process, which in turn affects the revenue cycle of the institution. Chart deficiencies may be in form of incomplete chart components, missing signatures, and in some cases, entire charts may be missing. Physicians can deal with chart deficiencies from any location of the Health Information System (Garber, Gross, & Slonim, 2010). The clinic achieved this using Chart Deficiency Tracker, which made it easy for the physicians to identify any chart deficiencies and monitor these (Garber, Gross, & Slonim, 2010). This tracker also enabled the supervisors to assign tasks related to chart deficiencies to specific physicians. Through this tracking system information was easily disseminated to physicians and the clinic’s staff. Patient charts were also completed more efficiently and in compliance with the recommended timelines and standards.
The clinic had discovered that relying on documentation in paper form to code charts delayed the receipt of and sending of information to and from coders causing delays in the billing of patients and further limiting the staff’s productivity (Garber, Gross, & Slonim, 2010).
Garber, Gross, & Slonim (2010) explained that when it comes to the disposal of health information, it is important that clinics and health providers apply caution to safeguard the privacy of health information. The clinic applied measures to avoid disclosure of patient information in disposal of charts and medical documents. For example, charts were shredded and later burnt in the clinic’s incinerator. Data on electronic media was cleared using software that overwrites it with data that was not sensitive.
The health and information management personnel are in charge of ensuring that medical charts are completed in timely manner to protect the clinic from legal suits and to improve the process and time of billing to increase productivity of the staff and the clinic’s revenue cycle (Garber, Gross, & Slonim, 2010).
References
Garber, J. S., Gross, M., & Slonim, A. D. (2010). Avoiding common nursing errors.Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Read More