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 Univeristy609-724-8139shirlelinke@yahoo.com