Shaquaris Magee Chapter 4 Real World Cases Drop Box

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University of Notre Dame *

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Information Systems

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Dec 6, 2023

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Shaquaris Magee 11/25/2023 1. Academy Hospital has implemented a new electronic record system and now the director of information systems feels that there is no need for the medical record committee to approve forms and other documentation that goes in the medical record. The proposal is that this function should be included in the operations of the IT department. What would be the response for the perspective of the HIM director? Answer: The Health Information Management (HIM) director might express concerns about the proposed shift of approval responsibilities to the IT department. They could emphasize the importance of maintaining a balance between technological efficiency and ensuring compliance with regulatory standards and accuracy in medical documentation. Collaboration between HIM and IT could be suggested to find a solution that addresses both technological advancements and the integrity of medical records. 2. Acme Physician Practice has purchased a new system that assists providers in creating patient notes and billing encounters from some basic input information. The physicians are excited because the system allows them to create a good note and then use it to paste into other encounters and edit. The billing manager is excited, and the entire office is happy about this discovery. As the HIM professional what is the most appropriate response? Answer: As the HIM professional, the most appropriate response to the excitement about the new system at Acme Physician Practice is to ensure that proper documentation and training are in place. Here are some steps to consider: 1. Assess the system: Begin by evaluating the new system to determine its capabilities, features, and potential benefits for the practice. This will help you understand how it can improve the efficiency and accuracy of patient notes and billing encounters. 2. Documentation standards: Establish clear documentation standards for the practice. This includes guidelines for creating patient notes and billing encounters, as well as templates or formats to be followed. These standards will ensure consistency and compliance with regulatory requirements. 3. Training and education: Develop a comprehensive training program to familiarize the physicians, billing manager, and other staff members with the new system. Provide step-by-step instructions on how to create, edit, and use the notes for different encounters. Offer opportunities for practice and hands-on experience to reinforce learning. 4. Privacy and security: Emphasize the importance of patient privacy and data security when using the new system. Educate the staff on best practices for protecting patient information, such as secure login procedures and password management. 5. Ongoing support: Establish a support system for staff members to address any questions, concerns, or technical issues they may encounter while using the system. This can include a dedicated help desk, training materials, and regular check-ins to ensure everyone is comfortable and proficient with the new system. By following these steps, you can help the Acme Physician Practice maximize the benefits of the new system, improve efficiency, and ensure accurate documentation and billing encounters.
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