HDIM 1010 Unit 3 M7 Exercises-1
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Jan 9, 2024
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HDIM 1010: Healthcare Delivery Systems
Unit 3: Healthcare Organizations
Module 7: Healthcare Professions
Exercises (43 points)
General Directions
: Beginning with Module 2, 1 point for each item will be deducted if these directions are not followed.
1.
Write your answers on this document in RED FONT
.
2.
Save this document with your last name as the first word in the file name before uploading it to the drop box as Hajek.mod1exercise.docx.
3.
Cite all resources used when the ideas are not general knowledge or your own. Place the citation
at the end of your answer to that exercise. Words taken verbatim should be in quotations. For your text, use the editor’s last name and page number. For web sites, include the name of the web site, the date accessed and the URL.
4.
Include your name on this document in the space provided.
Student Name: Samantha Fiala
Exercise 1: Healthcare Professionals (9 points)
HIM professionals work with all the healthcare professions who document and/or use health information to provide their healthcare services. HIM professionals must understand what is important to these professionals in order to achieve quality documentation and meet their user needs. Approaches
of “we need this documented to meet accreditation requirements” or “to secure reimbursement” do little to encourage the professionals to document correctly.
1.
Select one healthcare profession from the Unit 3 Module 7 Healthcare Professions Handout to investigate further
. You will need to research the professional association (similar to AHIMA is for
HIM professionals) web site to answer the following questions. 2.
Identify two key areas/topics/issues that are important to the profession selected. Look at position statements, recent publications to find the issues. The correct answer is NOT the functions of the profession. Do not include issues/topics that are important to the association such as increase in membership. Describe the rationale for selecting the topics of importance.
3.
Use these areas/topics/issues to develop a paragraph to send to this profession to encourage complete documentation in the medical record. In other words, you need to state how completing their medical records will benefit them in their profession. Exercise 1: Answers
(Fill in the answers to each item listed below.) https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-
practitioners.htm#tab-2
A.
Healthcare profession: Certified Registered Nurse Anesthetist (CRNA)
B.
Areas of interest and rationale: (4 points)
1
HDIM 1010: Healthcare Delivery Systems
Unit 3: Healthcare Organizations
Module 7: Healthcare Professions
Exercises (43 points)
1.
CRNAs work closely with physicians as they are putting the patient to sleep before surgeries and procedures. They order medications to keep up with pain management after the procedures are done. 2.
The CRNA documents all the vitals during procedures and discusses any medications that are currently being taken or will be taken after with patients before the procedures. The medication that they are on prior to surgery should be put in the patient’s chart. C.
Encouraging complete documentation. (5 points) Documentation in this profession is a huge priority. Making sure any medication that was given prior to the procedure and making sure the any adverse reaction to allergies must be documented so that there are no complications in the procedure. All vitals during procedure will be documented to show that patient was stable or unstable. This will have an effect on any procedures that are done in the future as well so the CRNA can see if there were any complications during a procedure or any medications that were given that did not work. Exercise 2: Healthcare Professions Case studies (20 points)
Directions: Using the following tables and the simulated medical records for Jesse and Raymond found in the Unit 3 Simulated Medical Record Folder:
1.
Excluding physicians, list five healthcare professions (list the profession not the person’s name) as included on the Health Professions Handout for Module 2, that are involved in the treatment of each patient. List each profession only once except for nursing. For nursing, include nurses who have different roles such as an operating room nurse and a floor nurse. Note: anesthesiologists, pathologists and radiologists are physicians. The record may not specifically identify the health professional who carried out the test or treatment. The types of documentation lead you to identifying the professional who carried out the service and recorded the results or treatment. For a lab report, identify the health professional who examines the specimen.
2.
Specify the professionals’ role in the care of each patient.
3.
Are health professions identified by the documentation of others and no documentation by that professional is in the record? Specify who and where it was documented. For example, respiratory therapists commonly are members of the team called to respond to a cardiac arrest in a hospital. Was a code called but the respiratory therapist did not document in the record?
Inpatient: Jesse
Healthcare Profession
Service Provided to
Patient
Date of
Service
Medical Record
Form
(Source of
information)
1.
Floor Nurse
Checked anesthetic 2/22
Orders.
2
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