Collection and Assembly of Medical Records - Essay Example

Collection and assembly of medical records The following training package is related to the collection and assembly of medical record and will be conducted at NHGA hospital. The sessions would help the attendees to equip themselves with the knowledge related to the retrieval and collection of medical records as well as arranging medical records’ forms with the Medical Records forms assembling guide (appendix two) as the standard. The training package includes three training courses, each seven hours long. It is to ensure that all Health Information Services Department (HISD) staff makes their presence available as it a mandatory training program. 2:0 Training Package Goals and Learning Objectives Table one: Training Plan Goals Learning objectives Learning methods / activities Evaluation Explain all aspects of medical records collection etc. Learn how to collect records from and return to wards and record department respectively. To confirm their return electronically. 1. Presentations. 2. Addressing the steps in collecting medical records. 3. Explaining confirmation of return steps. Evaluation of learning questionnaire Explain usage hospital information system for printouts Practicing taking printouts of medical record lists of discharged patient Coaching using Hospital Information System. Evaluation of learning quiz Explain the usage of assembly guidelines Assembling real medical records and the usage of medical record assembly chart Coaching using real medical record to explain the steps involved in assembling records Evaluation of learning questionnaire and quiz Source: McNamara, 2009 All of these objectives and goals have been decided and chosen through an extensive training needs assessment (appendix one) that was carried out during the planning and processing of the training package. The needs assessment result shows that participants are aware of the new policy and the factors leading to formulating such policies. Furthermore, the result highlights the high motivation of the employees for the new procedure in workplace and its effects on the quality of work. In addition to needs assessment, the formulation of training goals has been carried out in reference to Collection and Assembly of Medical Records policy, procedure number 123.2011. In each session, the trainers provide information about performing such tasks, supply relevant forms and guidelines, and illustrate the reporting system in case of any deficiencies. All participants are encouraged to work in teams to discuss a certain issue during the training sessions. They have to work on similar make-believe hospital information system to make sure that all the relevant steps involved in tracking files and printing out lists are fully covered and illustrated during the computer lab session. Table Two: Training Plan Time Table Time Topic Learning Objective Duration Location Delivery methods 09:00-09:10 Registration and reception To report all attendance to HISD 00:10 Theatre 111 09:10-09:40 Introduction to the training session. Illustrate the purpose of conducting the session 00:30 Presentation 09:45-10:30 Explaining the collection and retrieving of medical record Explain medical records collection; how, when and how often. 00:45 Presentation 10:30-10:45 Tea Break 00:15 10:45-12:00 Explaining printing out medical record list of discharged patients Practical activities on printing out records list of discharged patients 01:15 Computer Lab 124 Coaching 12:00-13:00 Lunch break 01:00 13:00-15:00 Information on assembling medical record chart and arrange forms Explaining the usage of medical record assembling guidelines (supplied as handout) 02:00 HISD Room 143 Coaching 15:00-15:30 Short quiz Evaluate participants’ understanding (supplied as handout) 00:30 HISD Room 143 Quiz 15:30-16:00 Group discussion and evaluation of learning progress Concluding the session and discussion on trainers, activities and knowledge grasped (supplied as handout) 00:30 HISD Room 143 Questionnaire Source: McNamara, 2009 3.0 Training Plan Learning Methods 3.1 Presentation / lecture Presentation is usually conducted by a subject expert and can be presented at various locations (McNamara, 2009). Under this training package, two presentations will be conducted, both in theatre number 111, as the theatre has required facilities such as computer, projector, and speakerphones. The presentations will be divided according to the topic and will incorporate question and answer session. Presentations will be handed out to the participants for reference. 3.2 Coaching Coaching is a useful learning method, plenty of which will be provided during the training time. It includes sessions where trainer will coach and teach participants to perform different tasks by demonstrating them (McNamara, 2009). Afterwards, the participants will have to perform the tasks themselves, under supervision of the trainers. Further feedback is also given to the participants for guidance. In addition to that, there are two coaching sessions. One of the sessions, which includes explanation and usage of tracking, is being held at computer lab 124 which has all the necessary equipments. It is equipped with all-important requirement such as computers, HIS virtual software, and white board for further explanation. 3.3 On-line material It is an electronic format of the training session, available online through the hospital intranet page. This online package provides examples, material and guidelines regarding the training session. A short quiz will also be taken to evaluate the learning progress of participants, who must be able to score eighteen out of twenty in it. Furthermore, evaluation of training program survey and training program questionnaire will be made available and must be completed at the end of the online session. A guideline will be sent electronically to all participants to guide them about ways to access the online material and set for their tests. Participants are encouraged to read the material before attempting the quiz. See online guide material and testing package. 4.0 Training Plan Implementation Strategy Several of strategies have been employed in the training program in order to attain the desired objectives. Some of them are: Lecture and presentation regarding the collection and assembling of medical record. Coaching session that involves one-to-one coaching in the computer lab and practicing real medical records charts at HISD. Learning evaluation, in the form of a quiz to ensure that the objectives of the training session have been achieved. Training plan evaluation to ensure that the trainers and training material support the delivery of information to the trainees. 5.0 Training Plan Documentation and Evidence of Learning Table Three: Training Plan Documentation and Evidence of Learning Documentation/ evidence of learning Who will evaluate it? How will they evaluate it? Objective one Participants Questionnaire Objective two Participants Quiz Objective three Participants Questionnaire Source: McNamara, 2009 6.0 Training Plan Quality Control As a part of quality control measures there are three main techniques that have to be addressed in order to achieve high quality programs .Each evaluation technique is taken as an opportunity to improve the quality. The first technique involves the attendance sheet which can determine participants’ behavior and motivation regarding the new work process. The second technique involves evaluation of learning which is in the form of questionnaires which must be completed by participants at the end of the session. They have the right to write comments regarding the session too. Also included is the training plan evaluation that helps to determine the usefulness of the material and the effectiveness of the trainers. The third technique helps measure the participants’ understanding of the topic presented. This technique comes in a quiz format and participants have to score eighteen out twenty so that the training program may be considered effective. See also training evaluation tool and testing package. 7.0 Training Plan Evaluation Training plan evaluation is considered as an important tool that helps in improving the quality of training sessions, support decision making .It also measures the usefulness of training mechanisms. It usually follows a series of systematic steps for collecting and analyzing information. The analysis of the feedback form of the participants help to measure the extent to which the desired objectives have been achieved (Raab et al., 1987). For the training plan evaluation, tools are included to evaluate the learning and the training plan. These evaluations vary in their format and can be questionnaire or short quiz forms. See testing package and training evaluation tools. 8.0 Face-to-Face Material Face-to-Face material consists of presentation slides that will be presented by an expert during the training session and supplied here as a separate file. 9.0 Online Guide Material The training session, materials, quizzes and questionnaires are available online on the hospital’s intranet page. All participants must take the online quiz after four weeks as a part of learning evaluation plan. They are required to get at least eighteen out of twenty mark. Each quiz consists of ten questions; seven are multiple-choice questions, three true/false questions. Each question is of two marks which makes a total of twenty marks. The objectives of these online quizzes are to measure the participants’ ability to retrieve information from the training session and to help improve the quality of training. See also testing package. See testing package. 9.1 How to access online material? To access the materials the trainees shall follow these steps: 1. Go to the hospital intranet icon 2. Go to employee login tab 3. Login using your badge number and password 4. Navigate to training tab a. To access the quiz directly, please follow these steps: I. Navigate to collection and assembly of medical record Training Package II. Choose collection and assembly of medical record quiz III. Click on start button when you are ready IV. Complete the quiz V. Make sure you save each answer VI. Upon finishing, click submit button VII. The result of the test will appear immediately and a copy of the result will be sent to trainer and HISD supervisor. b. To access the training package material, please follow these steps: I. Navigate to collection and assembly of medical record Training Package II. Press the button to explore the material and: 1. Click video link to watch the presentation 2. Click face-to-face link to access presentation slide and print. 3. Upon completion, click evaluation tool and: a. Click evaluation of learning to evaluate session b. Click evaluation of training plan to evaluate the training plan 10.0 Testing Package Short Quiz: 1. The collection of medical record chart is the responsibility of: A. HISD staff B. Ward clerks C. Patient escort D. Messengers 2. Upon the return of medical record chart, the chart is assigned to: A. Main filing area. B. Assembly section C. Coding section D. Incomplete medical chart section 3. If there are deficiencies or missing form in the medical record chart, HISD staff should: A. Use checklist and report manually B. Use checklist and enter deficiencies into HIS C. Use checklist only D. Report manually only. 4. Investigation reports must be: A. Filed in chronological order B. Checked and filed chronologically C. Sent to assembly section. D. None of the above 5. Records must be arranged according to: A. Date and time. B. Per medical record assembly guidelines C. A&B D. None of the above 6. How many times collection rounds made: A. One time B. Two times C. Three times D. Four times 7. If the medical record is free of deficiencies, it should be: A. Returned to main filing area B. Be sent after physician’s signature C. Assigned to coding section D. None of the above 8. Medical record should be stamped after assembling. A. True B. False 9. Outpatient forms are arranged from left to right, in chronological order. A. True B. False 10. Inpatient medical record chart must be with the most recent file. A. True B. False 11.0 Training Evaluation Tools 11.1 Evaluation of learning: Please consider the training session that you have attended and complete the following. Be completely honest in your assessments and answer the questions as fully as possible. Please circle the number that most closely represents you view. 1. The learning outcomes in this session are clearly identified Learning a lot 5 4 3 2 1 Learn nothing Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 2. The learning resources in this session help me to achieve the learning outcomes. Strongly agree 5 4 3 2 1 Not relevant Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 3. The assessment tasks in this session evaluate my achievement of the learning outcomes. Strongly agree 5 4 3 2 1 Not relevant Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 4. How would you rate the session overall Useful 5 4 3 2 1 Useless Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 5. Please comment on the most helpful aspects of this session _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 11.2 Evaluation of training plan: Please consider the training session that you have attended and complete the following. Be completely honest in your assessments and answer the questions as fully as possible. Please circle the number that most closely represents you view. To what extent you are satisfied with: 1. The trainers knowledge about the session and professional skills Knowledgeable and professional 5 4 3 2 1 Lack of knowledge Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 2. The location of the training session Easy to find 5 4 3 2 1 Needs a map Comment:________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. The equipment and the available facilities Useful 5 4 3 2 1 Useless Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 4. The air ventilation of the theater, and computer lab. Good 5 4 3 2 1 Poor Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 5. The advertisement of the training session Useful 5 4 3 2 1 Useless Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 6. The session time table Efficient 5 4 3 2 1 Not efficient Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ 7. The material handed in the session Useful 5 4 3 2 1 Useless Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________ Read More