HIT Professional Analysis

Medical professionals GP, Nurses and Doctors : They can examine, diagnose and treat. They can also record this can be photographic evidence.

The main objective of Beaumont Hospital is to provide high quality, efficient, accessible services, in a caring environment for Southeastern Michigan residents. Beaumont Hospital believes that patient safety is just as important as medical progression. Therefore, Beaumont Hospital’s risk management program consists of identifying hazard associated risks, controlling risks, and monitoring the effectiveness of procedures/practices. Risk is a part of patient care and services because everything doesn’t always go according to plan. Catastrophic patient injuries often occur because of unanticipated failures. The risk management team is responsible of effective surveillance, analysis, and prevention of events which may injure patients, lead to malpractice claims, or cause loss to the health care system. The risk management staff at Beaumont use the Failure Mode and Effects Analysis (FMEA) as a tool to anticipate what might go wrong with a process or product and how that failure effects the patient. FMEA is designed to dissect a particular process into its individual steps, isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal step, analyze the risk potential for the process, and assign and action plan to correct the problem (Fibuch & Ahmed, 2014). The risk management team also evaluates and modifies potential problems. Beaumont Hospital’s risk management team helps avoid or eliminate risks by identifying an alternate

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Given the complexity of healthcare system today, effective and efficient collaboration and communication among team members is critical to ensure patient safety. Daniel & Rosentein (2008) reported that during a typical patient’s hospital stay, a patient may interact with 50 different employees that may include doctors, nurses, laboratory technicians, etc. They also reported that when healthcare professional are not communicating and collaborating effectively, patient safety is at risk for several reasons: break in communication flow, misinterpretation of information, incorrect telephone orders and overlooked orders.

The institute of Medicine (IOM) has defined quality healthcare as safe, effective, timely, efficient and patient-centered care that is given to an individual regardless of their race, gender, financial status or health status (Wood & Haber, 2014). Quality initiatives are designed to help maximize efficiency; decrease poor work performance and resolve workforce problems through leadership, commitment and involvement (Abdallah, 2014). Abdallah (2013) also noted that trained physicians can help with the implementation of quality culture and employee morale, and it can help with the collaboration of ACNP and physician management. According to Chorostecki et al. (2015), interprofessional (IP) care includes shared decision-making, collaborative problem solving, respect in the work field, and equal contribution among all healthcare team members. Implementing effective interprofessional collaboration can help enhance quality care in hospital, acute, home or office settings (Chorostecki et al.,

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

The secondary audience, Human Resources, requires paper work for incidences and emergencies. A doctor’s note and a request are needed to clear the time off, and an incident report is needed to terminate the employee.

In the article, Introducing incident reporting in primary care: a translation from safety science into medical practice, the authors speak of how most reported incidents were ones that caused little or no injury to the patient. They found those providing care were able to deal with these incidents more

We know that he had sustained an at home fall. We learn that he has a history of pain and a prescription for oxycodone for back pain. We know that his vital signs on admission appear stable; he was not showing any signs of respiratory distress. As we look at the staff that was listed that day we do get the sense the hospital may have been short staffed. Staffing report shows there was one MD, one RN and one LPN managing at least 4 patients including- one patient was a child. Evidence based research has proven that the nurse to patient ratio is directly related to the patient outcomes (Stanton, 2004). It is important that we consider the staffing level that this rural ED as we know short staffing can be blamed for not being able to take the full amount of time needed to do a proper health history. A detailed health history is an imperative part of the care process; it is used by the staff to accurately assess any acute changes that may take place in the patient throughout their stay.

The fifth member of the team is the medical records manager. She has a bachelors in healthcare management. Her expertise with HIPAA rules and regulations is crucial. It is her job to evaluate security of the new systems to ensure that patient confidentiality is not breached. She will have input form other healthcare managers as well as others in the medical records department.

Inspect and manage medical records to insure that the correct information is being used for the right patient.

Managers also inform Specialist personnel who include the Health and Safety Executive, the Department of Health and the Infection Control Doctor. The Specialist personnel such as The Infection Control Team, then inform the media if the case is in the public’s interest for example if it was a case of HIV, Swine Flu or measles. The Non-Care staff, such as a Domestic Assistant, needs to report anything they have seen or heard during work to the nurses.

Has direct contact with injured sports individuals as they are under rehabilitation and will make the final say as to when an athlete is cleared

The first component, proactive encounter is a team- based care in all settings. It has three phases which are assessing the patient during pre-encounter, assist and provide standardized care for the patient during encounter, and provide information and instruction for follow up during post- encounter. Benefit from the proactive encounter were numerous, it helps the care providers to identify missing lab that may be critical, it helps to reduces making error in care, and it provide client informative information to follow up. Next, KPSC develop several team to manage different situations, also known as the panel management. It is a tactic of having multiple team to work together in harmony instead of overwhelming an individual with loads of responsibilities. It eases out the work for every individual in order to provide optimum focused care. For example, case manager will be taking care of clients who needs long term support, health educator will be educating clients, and team nurses will provide quality care. Last, clinical information system and decision support will be helping the client to provide real time laboratory, radiology, and other clinical data available to providers to enhance the best point of care. The result was significant with the use of a complete care program, and it had made KPSC one of the

The role and responsibilities of a Health Information Technician (HIT) also known as a Medical Records Technician include maintaining the medical information system of a healthcare facility in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements. Responsibilities include organizing and coding patient records, recording information on patient records, the gathering of statistical and research data, monitoring information to ensure confidentiality and medical coding for billing purposes. Technicians communicate on a regular basis with physicians and other healthcare professionals to obtain information and clarify diagnosis. This is one of the only fields in the healthcare system that you will not have