Overview
The purpose of this first professional practice is to give you experience in health information management and for you to become familiar with how to adhere to government regulatory standards, accreditation guidelines, and quality improvement initiatives. Your participation in this professional practice experience enables you to apply many of the concepts of health informatics and information management that you have been studying.
In this task, you will complete EHR Go activity questions that allow you to apply theory to practice. In addition, you will use your knowledge of health informatics and information management to explain how hospitals can ensure regulatory compliance and to describe the importance of basic skills, such as selecting the correct principal diagnosis and ensuring appropriate coder productivity. You will explain the importance of confidentiality and ethical behaviors as an independent health information professional.
Your submission must represent your original work and understanding of the course material. Most performance assessment submissions are automatically scanned through the WGU similarity checker. Students are strongly encouraged to wait for the similarity report to generate after uploading their work and then review it to ensure Academic Authenticity guidelines are met before submitting the file for evaluation. See Understanding Similarity Reports for more information. Grammarly Note: Professional Communication will be automatically assessed through Grammarly for Education in most performance assessments before a student submits work for evaluation. Students are strongly encouraged to review the Grammarly for Education feedback prior to submitting work for evaluation, as the overall submission will not pass without this aspect passing. See Use Grammarly for Education Effectively for more information. Microsoft Files Note: Write your paper in Microsoft Word (.doc or .docx) unless another Microsoft product, or pdf, is specified in the task directions. Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc. All supporting documentation, such as screenshots and proof of experience, should be collected in a pdf file and submitted separately from the main file. For more information, please see Computer System and Technology Requirements.
A. Explain how different departments within a hospital could work both independently and collaboratively to ensure all elements of the “Record of Care, Treatment, and Services (RC)” standard from the Joint Commission quality improvement and accreditation standards are met.
B. Explain why a patient’s medical record is considered an integral part of the Joint Commission’s tracer methodology for quality improvement and accreditation standards.
C. Discuss why the Centers for Medicare and Medicaid Services (CMS) utilize the Uniform Hospital Discharge Data Set (UHDDS).
D. Explain why the selection of the correct principal diagnosis is critical, based on your knowledge of billing and reimbursement.
E. Describe what a user would discover if searching for an ICD-10 code (with the supplied encoder) for “gastroesophageal” or “GERD” instead of for “gastro-esophageal,” including what this indicates about search protocol for ICD codes.
F. Discuss three strategies that could be used to maintain the average coding productivity in a department when a new coder is hired.