HIMS 655 UMDC Wk 9 Clinical Documentation Improvement Paper

FIND A SOLUTION AT Academic Writers Bay

Policy Number: EHR 015 Organization Title Subject: Electronic Health Record Duplication Page: 1 of 4 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: April 1, 2022 Corporate Director of Health Information Management SUBJECT: Minimizing health records duplication through the use of biometrics. PURPOSE: This policy aims to offer a potential solution for minimizing EHRs duplication, which has been a growing concern as it can result in compromised data accuracy, medical care, patient safety, and reimbursement. The use of biometrics offers an effective approach for solving, preventing and managing duplicate medical record issues. STAFF: This policy applies to all registration employees who are tasked with creating and/or updating patients’ records, including the Medical Records Manager, who is tasked with managing and overseeing the medical records function within the healthcare organization. THOROUGH DESCRIPTION OF THE POLICY: Documentation integrity is considered a critical aspect in healthcare as it refers to the accuracy of the complete health record (AHIMA Work Group, 2013). Caregivers rely on the information contained in health records to inform their decisions, hence the need to incorporate effective safeguards to ensure the information contained in the records is accurate. Duplicate medical records are a common data quality issue that threatens documentation integrity, and jeopardizes the quality of care offered to patients (Harris #038; Shannon, 2018). However, rapid advances in technology have provided organizations with new solutions and tools for addressing duplicate medical records. This policy calls for all registration employees to adopt the use of biometrics during the patient registration process to help address EHRs duplication. Registration employees are required to Policy Number: EHR 015 Organization Title Subject: Electronic Health Record Duplication Page: 2 of 4 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: April 1, 2022 Corporate Director of Health Information Management undergo a 1-month training which will equip them with the necessary knowledge and skill for effectively adopting the new change. This policy aims to ensure the patients’ physiological characteristics are captured by scanning their biometric identity during registration. Embracing biometrics will help minimize the chances of health records getting duplicated as a patient’s biometric identity will ensure patients have only one record each. DEFINITION OF TERMS ASSOCIATED WITH POLICY: Biometrics refers to body calculation and measurements that relate to human characteristics, which can be used to identify individuals. Biometric identity involves applying statistical analysis to an individual’s biological data (Harris #038; Shannon, 2018). Electronic Health Record Duplication refers to a common data quality issue that involves a patient being assigned more than one health record number (Harris #038; Shannon, 2018). This often occurs due to errors or mistakes made during the patient identification process. Physiological characteristics refer to the structural information of a patient’s body, which includes iris, face, and fingerprint, among others. PROCEDURE: Training will commence on February 1, 2022, and will be conducted for 30 days. Employees will then have up to April 1, 2022, to ensure they are sufficiently knowledgeable of how to effectively incorporate biometrics into Electronic Health Records. Policy Number: EHR 015 Organization Title Subject: Electronic Health Record Duplication Page: 3 of 4 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: April 1, 2022 Corporate Director of Health Information Management Once the policy is in effect, all records created afterward will be required to capture the patients’ biometric identities. PENALTY FOR FAILURE TO COMPLY: Documentation integrity is a rather sensitive issue that affects patient care and care coordination. Therefore, in the event a patient’s health record is duplicated as a result of due negligence and/or mishandling of information on the part of an employee, the penalty will be a suspension of a period not exceeding 60 days. However, in severe circumstances where multiple records are duplicated, parties responsible will have their employment contracts terminated. Policy Number: EHR 015 Organization Title Subject: Electronic Health Record Duplication Page: 4 of 4 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: April 1, 2022 Corporate Director of Health Information Management References AHIMA Work Group, (2013). Integrity of the Healthcare Record: Best Practices for EHR Documentation. Journal of AHIMA 84(8), 58-62. Gandhi, T., Lehmann, C. U., Michel, J., Possanza, L., Solomon, R., #038; Tsou, A. Y. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1): 12-34. DOI: 10.4338/ACI-2016-09-R-0150 Harris, S. #038; Shannon H. H. (2018). Double Trouble—Using Health Informatics to Tackle Duplicate Medical Record Issues. Journal of AHIMA, 89(8), 20–23. Policy Number: EHR 016 Organization Title Subject: Copy and Paste Functionality Page: 1 of 5 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: 1st February, 2022 Corporate Director of Health Information Management SUBJECT: The copy and paste functionality are one of the capabilities of the operating systems of electronic health records (EHRs) that helps improve the ease of use, documentation efficiency, and stability of medication lists (Gandhi et al., 2017). However, in some cases, the copy and paste functionality results in redundancy, longer and poorly organized notes, and the inclusion of outdated and inconsistent information (Gandhi et al., 2017). For the copy and paste functionality to serve the purpose, it was intended and for it to make the use of EHRs easier for individuals working in healthcare, policies must be composed to govern its use. PURPOSE: This policy will ensure that the use of the copy and paste functionality will adhere to the standards and criteria that exist concerning its appropriate use. It will also make sure that the use of this functionality will be following the existing Federal and State regulations on healthcare documentation and the integrity of patient data. STAFF: The staff that will be required to adhere to this policy include all healthcare providers who will at any point handle patient data. The following include (but are not limited to) staff who will be affected by the implementation of this policy: physician and non-physician providers who make use of the EHRs. THOROUGH DESCRIPTION OF THE POLICY: In this case, the following policy will be implemented to ensure the effective use of the copy and paste functionality: The integrity and Policy Number: EHR 016 Organization Title Subject: Copy and Paste Functionality Page: 2 of 5 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: 1st February, 2022 Corporate Director of Health Information Management quality of the EHR will be preserved by observing specified standards in recording information that is updated, complete, brief, and accurate to produce useful and clear medical records. The EHR should only document clinical procedures that are performed on every patient each day. The copy and paste functionality should only be used in a way that is thoughtful, accurate, necessary, and beneficial to the health outcomes of the patient. DEFINITION OF TERMS ASSOCIATED WITH POLICY: Electronic health records (EHRs) are electronic documentation of patient data, which provides an accurate depiction of the current health status of the patient and any other relevant information. Data integrity is the preservation of the consistency and accuracy of data throughout its lifecycle. Copy and paste functionality is a time-saving tool that allows users to portions or entire parts of already existing information. Physician providers are all attending physicians, including dentists, Medical Doctors, Doctors of Pediatric Medicine, and Dentists. Non-physician providers include; nurse practitioners, physicians’ assistants, and certified nurse-midwives. Policy Number: EHR 016 Organization Title Subject: Copy and Paste Functionality Page: 3 of 5 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: 1st February, 2022 Corporate Director of Health Information Management PROCEDURE: The physician and non-physician providers will be briefed on the policies that will be implemented on the effective use of the copy and paste functionality. They will be expected to comply with the acceptable use of this tool by (AHIMA, 2013): a. Using the Automatic Data Recall function to keep track of any changes made to the original documentation. b. Differentiating historic from present conditions using a mechanism that makes the copy and paste material easily identifiable. c. Avoid the use of copy and paste functionality to copy historic patient data to reproduce it in present patient data or another patient’s records. d. Summarizing test results instead of reproducing all the results directly, and only using the notes of other providers for reference instead of reproducing them entirely. PENALTY FOR FAILURE TO COMPLY: Any identified non-compliance issue is usually automatically forwarded to the Chief Medical Information Officer (CMIO) along with the details of the provider involved, the record number of the medical record, and the noncompliance issue. The provider at fault will then be summoned by the CMIO to review the Policy Number: EHR 016 Organization Title Subject: Copy and Paste Functionality Page: 4 of 5 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: 1st February, 2022 Corporate Director of Health Information Management issue. If the issue persists, then the CMIO will forward the issue to the Chief Medical Officer (CMO), who will also review the issue with the provider. Further non-compliance will prompt the CMO to forward the issue to the Chief of Staff, who will initiate specified procedures to deal with the non-compliance issue. These procedures follow but are not limited to Education, Monitoring, and Corrective Action following Medical Staff By-Laws. Policy Number: EHR 016 Organization Title Subject: Copy and Paste Functionality Page: 5 of 5 Department: Health Records ACTION: ◙New Policy □Repealed Policy Date_____________________ □Superseded Policy Number________________ Effective Date: Approved by: 1st February, 2022 Corporate Director of Health Information Management References AHIMA Work Group, (2013). Integrity of the Healthcare Record: Best Practices for EHR Documentation. Journal of AHIMA 84(8), 58-62. Gandhi, T., Lehmann, C. U., Michel, J., Possanza, L., Solomon, R., #038; Tsou, A. Y. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1): 12-34. DOI: 10.4338/ACI-2016-09-R-0150 Harris, S. #038; Shannon H. H. (2018). Double Trouble—Using Health Informatics to Tackle Duplicate Medical Record Issues. Journal of AHIMA, 89(8), 20–23. 1 Data Quality Beyond Borders: Modernizing Health Information Infrastructure using AHIMA’s Data Quality Model Data Quality Checklists 1. AHIMA’s Data Quality Management Model (DQM) Data Quality Data Quality Measure(s) Characteristics Select Yes or No if the Comments record meets the data quality measures Accessibility The data can easily be accessed and clarity by the relevant parties. The data is presented clearly. Yes According to AHIMA, the accessibility and Yes clarity of data are quality characteristics. Accuracy The data correctly represents the Yes variables it was meant to measure. Relevance The importance of precision in data quality The data is free of errors. Yes is highlighted. The data meet users’ current Yes Data should be useful for needs. the purpose for which it The data meet users’ future needs. Yes was intended. The data is current. Yes Data must be up-to-date, The data is released as scheduled. Yes useful, and operative. Comparability The data can easily be used by No AHIMA does not and coherence other authorized individuals for Timeliness comparison purposes. highlight the importance No 2 The data is consistent over time. of this data quality characteristic. Compliance The data is compliant with all Yes local, state, and federal regulations. AHIMA highlights the importance of Yes The data is compliant with all compliance as a data quality characteristic. organizational policies and ethical procedures. 2. CIHI’s Data Quality Framework (DQF) Data Quality Data Quality Measure(s) Characteristics Select Yes or No if the Comments record meets the data quality measures Accessibility The data can easily be accessed and clarity by the relevant parties. Accuracy Yes accessibility and the The data is presented clearly. Yes clarity of data. The data correctly represents the Yes CIHI states that data must variables it was meant to measure. Relevance CIHI insists on the be correct and consistent. The data is free of errors. Yes The data meet users’ current Yes needs. The data meet users’ future needs. According to CIHI, quality data must meet both the 3 Yes present and future needs of the user. Timeliness The data is current. Yes According to CIHI, quality The data is released as scheduled. Yes data must be current and released as scheduled. Comparability The data can easily be used by and coherence other authorized individuals for data must be consistent comparison purposes. over time and across The data is consistent over time. Yes Yes CIHI states that quality providers, and it can easily be used in conjunction with other sources. Compliance The data is compliant with all No local, state, and federal regulations. CIHI fails to mention compliance as an No The data is compliant with all important characteristic of data quality. organizational policies and ethical procedures. Limitations Found in Each Model The limitations found on AHIMA’s Data Quality Management (DQM) model from the data quality checklists above are comparability and coherence. Comparability and coherence are important quality characteristics of data that allow data to be used consistently over time and with different relevant parties (CIHI, 2017). This quality data characteristic is highlighted by 4 CIHI’s information quality framework. The limitations found on CIHI’s Data Quality Framework from the data quality checklists above is on compliance. Compliance with local, state, and federal standards as well as accreditation agencies’ and healthcare organizations’ ethical standards, policies, and procedures is an important quality characteristic of data quality (AHIMA, 2015). Compliance is highlighted by AHIMA as an important quality characteristic. Final Recommendation to AHIMA’s Global Workforce AHIMA’s global workforce should consider adopting modern and relevant data quality standards. Among the revisions that may be made to the current data quality management model is the addition of comparability and coherence to the association’s data quality management model. Comparability and coherence are qualities that ensure that healthcare data can be used by different parties in the present and the future (CIHI, 2017). Additionally, these qualities make sure that the data in question can easily be incorporated into other sources (CIHI, 2017). This way, researchers can make use of this data as a reference for their current and future research endeavors. This data can act like a baseline or a point of reference since it is reputable. These changes will place AHIMA at the frontline of issues related to quality data and research. Concerns in the Development and/or Use of the Data Quality Checklists The development and use of data quality checklists bring up concerns such as the inclusion of all the relevant measures and exclusion or relevant measures. Different researchers have come up with different data quality checklists with some data quality measures being consistent while others vary. Developing a data quality checklist is a challenge in this case because knowing which data measures to include and what to exclude can be a challenging task. Additionally, differentiating between some measures may be difficult as some quality measures 5 are similar to others. In some cases, one may find oneself using some quality measures interchangeably, yet they are different. One must find the definition of these quality measures as a way of differentiating them instead of using them interchangeably. For exle, the quality measures precision and accuracy are similar measures. However, they cannot be used interchangeably. 6 References American Health Information Management Association (AHIMA). (2015). Data quality management model (2015 update) – retired. Retrieved from https://library.ahima.org/PB/DataQualityModel#.YfaN2_hRXre Canada Institute for Health Information (CIHI). (2017). CIHI’s information quality framework. Retrieved from https://www.cihi.ca/sites/default/files/document/iqf-summary-july-262017-en-web_0.pdf

Order from Academic Writers Bay
Best Custom Essay Writing Services

QUALITY: ORIGINAL PAPER NO PLAGIARISM - CUSTOM PAPER

Why Choose Us?

  • non-plagiarized Papers
  • 24/7 /365 Service Available
  • Affordable Prices
  • Any Paper, Urgency, and Subject
  • Will complete your papers in 6 hours
  • On-time Delivery
  • Money-back and Privacy guarantees
  • Unlimited Amendments upon request
  • Satisfaction guarantee
SATISFACTION
SATISFACTION

How It Works

  • Click on the “Place Your Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
  • Fill in your paper’s requirements in the "PAPER DETAILS" section.
  • Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • Click “CREATE ACCOUNT ; SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

About AcademicWritersBay.com

AcademicWritersBay.comnbsp;is an easy-to-use and reliable service that is ready to assist you with your papers 24/7/ 365days a year. 99% of our customers are happy with their papers. Our team is efficient and will always tackle your essay needs comprehensively assuring you of excellent results. Feel free to ask them anything concerning your essay demands or Order.

AcademicWritersBay.com is a private company that offers academic support and assistance to students at all levels. Our mission is to provide proficient andnbsp;high quality academic servicesnbsp;to our highly esteemed clients. AcademicWritersBay.com is equipped with competent andnbsp;proficient writersnbsp;to tackle all types of your academic needs, and provide you with excellent results. Most of our writers are holders ofnbsp;master's degreesnbsp;ornbsp;PhDs, which is an surety of excellent results to our clients. We provide assistance to students all over the world.
We provide high quality term papers, research papers, essays, proposals, theses and many others. Atnbsp;AcademicWritersBay.com, you can be sure ofnbsp;excellent gradesnbsp;in your assignments and final exams.

NO PLAGIARISM
NO PLAGIARISM
error: Content is protected !!