Download - Shirlee Linke Practicum Portfolio
Shirlee LinkePracticum Portfolio
HIT 272Spring 2016
Objectives and Goals
Pursue Associates of Applied Science degree in Health Information TechnologySummer 2016-Anticipated graduation from DeVry University2016-Registerd Health Information Technician (RHIT) Certification ExaminationObtain employment in Medical RecordsExplore training as Compliance AuditorPursue education to become Compliance AuditorObtain employment within the Department of Health, as a Compliance Auditor
Practicum Experience Highlights
Observed use of Hybrid Medical Record System Use of electronic and paper medical chart
Format and filing is according to facility needs Different facilities require different information
to provide treatment; filing is tedious but necessary
Thinning Records keeps only current orders in the chart
Coding is done using electronic record
Organization is vitally important in Medical Records
It takes an organized, detailed-oriented individual who can work independently to perform the functions of a Medical
Records Technician
Medical Records
Admission Audito Performed 3 days after admission to confirm required
documentation and assessments were completedo Use of electronic and paper record
Discharge Audito Performed within 30 days after discharge to confirm all
documents were signed and all paperwork has been returned to the recordo Paper record only
Quarterly Audito Performed on current patients’ medical charts only
o Use of electronic and paper record
This is Quantitative and Qualitative Analysis! I was responsible to
check that all required documents were in the record, the
information was accurate, and that it was completed within the
required time.
Audits
Patient Requestso 48 hours to respondo Risk Manager, Administrator, and Lawyer quick review
Another Healthcare Facility Requestso Request must be made on letterheado Must state what information is neededo Does not need to be reviewed prior to releaseo Used for continuum of care to the patient
Third-Party Requestso Request must be a written requesto Must contain all patient’s informationo Must be accurateo Electronic and Paper records are copiedo Must be reviewed extensively by Risk Manager, Director of
Nursing, Administrator, and Lawyer prior to releaseo 30 days to respond to requesto Requestor must pay a fee for the record
Release of Information
Morning Meetingo Provides the facility’s daily censuso Department Heads provide daily goals
QAPIo Quality Assurance and Performance Improvemento Leadership responsibilityo Develop an Approacho Facility Self-Assessmento Identify Principleso Develop Plano Conduct Awarenesso Develop Strategy to collect and use datao Identify Gaps and Opportunitieso Prioritize Qualityo Plan, Conduct and Documento Take Action
Facility Meetings
Activity Log by TCO for HIT272DeVry University
Health Information Technology Practicum
Student’s Name Shirlee Linke Dates of Affiliation 2/29/16 to 4/21/16
Facility Silver Lake Nursing Center Practicum Director Theresa Oliphant
Date Activity Details TCO Comment(s)3/4 3/83/224/54/74/124/154/18
Census ReportAuditingClose discharged recordsThinning chartsPre-authorization
1 Hybrid systemCAA (comprehensive worksheet)Minimum Data Set (MDS)
3/43/224/54/74/154/18
Auditing 2 Quantitative and qualitative analysisAdmission Audit-quantitativeClosed Audit-both (must be done within 30 days of discharge/expire/transfer)Quarterly Audit-both; done on current patients (paper and electronic is used)
3/114/15
AuditsDisclosure logs
4 Audits are recorded on a registry form to confirm all information is provided; if not, a copy is provided to each dept with highlighted info neededDisclosure logs are necessary to log information for requested records; information is kept separate from medical record and available for review/audit
4/74/15
Patient Record Requests 5 Patient can request record; must be provided within 48 hoursHealthcare facilities request records for continuum of care
4/194/21
HIT Manual 6 Provides information on policies and procedures for Medical Records coordinator in the facility
3/113/18
Release of Information 7 Must be requested my authorized person; must be accurate; must be review by Risk Manager, Administrator and facility lawyer prior to being released; there is a fee associated with receiving a record
4/18 Facility hardware and software 8 Facility uses PointClickCare (PCC) to enter patient information, orders, assessments; codes are displayed in this system
3/29 Morning Meeting; QAPI 9 Morning Meeting is a great way to start the day; reviews daily activities at the facility and the census for the dayQAPI is a meeting held with all depts to provide info to improve quality and performance
DeVry University HIT272Health Information Technology Practicum Journal
Name: Shirlee Linke
Date Function or Work Area
Activities Performed or Observed Time Spent
What was gained from the experience?
2/29Medical Record
Basics of SNF records dept; does not code; uses hybrid system;
6 hours
Organization is very important
3/4Census Review daily census to see if
anything has changed; discharged; expired; transferred
1 hour Census is the start of the day; provides what charts need to
be closed3/4 Audit Auditing closed charts 5
hoursNeed to be detail-oriented; all
orders must be signed; patient’s name must be on both
sides of 2-sided forms
3/8Closing and
New Admission
Closing a medical record for discharged, or expired patients; making New Admission charts
6 hours
Closing a chart is just pulling paperwork from paper record to
be audited. Then a New Admission chart should be put
on floor
3/11Patient Record Request
Requests were made by patient and healthcare facility for discharged
patients
5 hours
Only pull requested documentation; patient
requests by the patient must be provided in 48 hours; these requests do not need to be
reviewed by the lawyer3/11 Disclosure
logLog requests made for discharge
patient record1 hour Any request must be logged
prior to release.
3/18ROI Requests for patient records made
from a 3rd party, such as an attorney, or family member-current and
discharged
5 hours
These requests must provide all accurate info; if anything is
wrong, such as DOB or spelling of name, request is denied.
These requests must be reviewed by RM, Admin, and
lawyer prior to release
3/18ROI ROI Disclosure log-mult logs for
facility, HIPAA1 hour This log is more detailed since
it is a 3rd party requesting info that has nothing to do with
continuum of care
3/22Medical Record
Thinning current patients’ charts 6 hours
SNF has long-term patients; records get thick and messy-
very hard to manage. Thinning removes older info and leaves the current orders/labs for the
physicians.
3/29Management
MeetingQAPI, Quality Assurance and Performance Improvement
6 hours
This provides information from all depts to improve
performance4/5 Medical
RecordsThinned Unit 2 records 6
hours
4/7Audit Auditing closed charts 6
hoursThis is done within 30 days to make sure all forms are signed and all information is accurate
4/12Medical Records
Pre-Authorization prior to admission-request is made to admit patient;
confirm medical insurance and coverage
6 hours
This is necessary so the facility knows if the patient has
coverage to receive treatment, or if it will be billed. Info is provided to patient prior to
admission, so if out of pockets fees will incur, that patient is
not shocked.4/15 Audit Quarterly Audits-performed each
quarter using both paper and electronic record for current patients
6 hours
This is performed to confirm all orders are current and signed
and all assessments have been performed
4/18 Audit Admission Audits-performed on each new admission within 3 days of
admission, then again at 7 days and lastly 22 days (I performed audits on
closed charts as well just for practice).
6 hours
Paper and electronic system is used; this must be performed to confirm paperwork and consent
was signed and admission assessments were performed
4/19 HIT Read HIT Manual for SNF 6 hours
Provided policies and procedures for Health Info
Technician in a Skilled Nursing Facility
4/21 HIT Reviewed HIT Manual and said goodbye
2 hours
I will enjoy my new career as a RHIT
Final Analysis
My experience at Silver Lake Center brought my education to life. Theresa is very knowledgeable as a RHIT. She has made me continue my excitement as I begin my new journey in the healthcare industry. I am looking forward to joining Theresa as a fellow RHIT.The practicum experience allowed me to explore areas that I have been taught in the last few years. This was a wonderful opportunity to make my decision on where I would like my career to lead me.Silver Lake Center and its staff welcomed me with open arms and I have much appreciation and gratitude. I am thankful to DeVry for this experience.
April 21, 2016
Theresa OliphantMedical Records CoordinatorSilver Lake Nursing Center905 Tower RoadBristol, PA 215-785-3201
Dear Theresa,
Thank you for the opportunity to complete my practicum for DeVry University at your facility. I appreciate the time you took out of your busy schedule to teach me about the Medical Records field in a Skilled Nursing Facility. I learned a lot from you in the last eight weeks. It has helped me to make a decision where I would like to pursue my new career. Please thank everyone at the facility for their kindness and welcoming me into your facility. Also, please extend my gratitude to the Administrator for allowing the opportunity for me to complete my DeVry Practicum. I highly recommend your facility to future DeVry students. I am very proud and thankful to add my time at your facility to my resume. You have given me a great start into Health Information Technology.
Warm regards,
Shirlee Scott
Shirlee ScottDeVry [email protected]