8-1 Discussion

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Southern New Hampshire University *

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Health Science

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Oct 30, 2023

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1 8-1 Discussion: Performance Management and Patient Safety Brief Summary of Performance Measurement and its Key Concept: The Documentation Compliance Rate measures the extent or the level to which healthcare professionals comprehensively and accurately document patient information in electronic health records (EHRs) (Poulos et al., 2021). It significantly assesses the completeness, accuracy, and timeliness of patient health record documentation. In the context of completeness, it ensures that all relevant patient information, such as diagnoses, treatment plans, medications, and progress notes, is thoroughly documented. At the same time, accuracy is fundamental in ensuring that the information documented in the EHR is correct and error-free. Timelessness, however, is essential to maintaining up-to-date patient records, which can aid in delivering safe and effective care. Significance to an HIM Professional: An HIM (Health Information Management) professional plays an anonymous role in ensuring the compliance and integrity of patient health records (Costa Lima et al., 2023). Their crucial role is to oversee documentation practices, coding, and maintaining accurate records. The Documentation Compliance Rate is significant to HIM professionals, highlighted by its significant direct impact on the quality of healthcare data, billing accuracy, and patient safety. Additionally, accurate and complete records are essential for reimbursement, compliance with regulatory requirements, and improving patient care. Using the EHR System: In the context of Documentation Compliance Rate, I would use the EHR system to conduct regular audits of patient records. Moreover, they can develop queries or reports to identify gaps in documentation, missing information, or inaccuracies. As a result, they can comprehensively help in pinpointing areas for improvement and tracking progress over time. EHR systems can design queries and generate reports to navigate into the specifics of documentation compliance, which, in turn, allows for the identification of gaps in

2 documentation, missing information, and inaccuracies in patient records. The data collected from these audits acts as a basis for assessing compliance and offers insights into areas that may require intervention or staff training. Additionally, I can utilize an EHR system to track these metrics over time, enabling HIM professionals to monitor the effectiveness of their initiatives and ensure a consistent standard of documentation quality. Example Visual Months Documentation Compliance Rate January 80% February 85% March 82% April 88% May 90% June 92% July 93% August 91% September 89% October 87% November 85% December 88% Janu ary Februa ry Mar ch April May June Jul y August September October November December 70% 75% 80% 85% 90% 95% Documentation Compliance Rate Column1

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