Learning Experience Journal Entry – Director of Health Information Management and the Supervisor of Medical Records Coder The purpose of this paper is to describe the role and functions of the Director of Health Information Management and the Supervisor of Medical Records Coder. I will provide a synopsis of what I observed and the activities I participated in during the learning experience. In addition I will provide an analysis of their primary roles and functions as they relate to nursing and patient services. Additionally, I will provide insights I have gained into the leadership behaviors or style as a result of my observations and interactions. Finally I will summarize my learning experience by comparing my observations to sources from …show more content…
As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for the charts to be coded properly for billing purposes is within four days of the patient discharge. Therefore her interaction with all clinical departments and physicians throughout the organization, for the completion and accurate documentation of medical records in a timely matter, is vital to generate the revenue necessary for the organizations …show more content…
They monitor, evaluate, and communicate about proper documentation between the disciplines. Through the effective collaboration of the medical coders, both quantitative and qualitative improvements in health care delivery can be achieved (Nursing Economics, 2004). A medical coding professional works as part of a team to achieve the best quality patient care with physicians, clinical departments, and insurance companies. Insights: Supervisor of Medical Records Coder The medical records coder has significant influence on the financial stability of an organization; they manage the revenue cycle. Kim and her crew have a huge financial impact on both the patients and medical facilities. A patient's diagnosis and the treatments received are some of the main factors in determining the amount of money that a hospital gets from an insurance company ("Medical billing and coding," 2011). Appropriate reimbursement for health care organizations is dependent on accurate coding of the patient medical records (Hoffman & Jones, 1993). Summary: Supervisor of Medical Records
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
Mentors practitioners new to the field of Health Information Management professional’s mission, values, and ethical principles.
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In 1983, the Medicare prospective payment program was implemented, which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007).... ... middle of paper ... ... Case Management Related to Other Nursing Care Delivery Models.
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According to the American Health Information Management Association, Health information is the data related to a person’s medical history, including symptoms, diagnoses, procedures, and outcomes. Health information records include patient histories, lab results, x-rays, clinical information, and notes. The data can be analyzed to see how a patient’s health might have changed. I took interest in Health Information Management when it was brought to my attention by a doctor. He told me that is a very interesting field and it is in high demand as they have more jobs than people to fill them. I went home, researched it and now here I am making my entry into the field.
Laureate Education, I. (Producer). (2010). Quality improvement and safety [DVD]. In The nurse leader: New perspectives on the profession. Baltimore. MD
Clinical Nurse Leaders’ responsibility scope includes all nurse and patient management details except for administrative duties. They are important resources in United States medical intuitions. CNL candidates must have a master’s degree to fulfill this position. This knowledge gives them the needed skill set to manage the daily operation of the hospital’s entire nursing pool. They also observe and regulate the patient care setting. Ultimately, the Clinical Nurse Leaders’ role will continue to gain importance as healthcare caseloads increase in
What is HIE? What does HIE stand for? HIE stands for Health Information Exchange. Health information exchange is where healthcare information is moving across the different organization that is between a community or hospital system. HIE lets doctors, nurses, pharmacists, and other providers and patients access health information to share patient information. HIE also improve safety, and the terrible cost of patient care. Honestly, HIE along with HIT is basically still being defined in the United States, meaning they are still trying to find out what purposes is it serving in the United States. In some ways HIE is still struggling with many things that are included in federal and state grants. However, with all this HIE still provide a great
In the midst of changes occurring in the United States one experiment currently taking place is with new reimbursement arrangements called pay-for-performance. In pay-for-performance physicians performance becomes tied to quality. Pay-for-performance is likely to face challenges ahead as it is implemented and utilized in the United States through adoption of electronic medical records. This paper will cover those possible challenges along with addressing general concerns.
When talking about leadership, one cannot help but wonder how it relates to nursing. If the focus of nursing should be caring for patients who are either well or ill, then why is there a need to tackle leadership? Unlike before, today’s health care environment is complex, rapid and continuously changing. This development prompts an upcoming danger to the nurse’s skills, identity and ability to coordinate with other health care professionals. On the other hand, this also makes nurses challenge their own into taking the lead, developing goals, consolidating a purpose and moving towards an attainable vision. A nurse leader then needs to combine clinical, administrative, financial and operational skills to effectively solve various clinical challenges. These challenges are the rationale behind tackling the need for leadership in nursing.
Leading and managing take on different meanings depending on one’s perspective. A registered nurse (RN) in healthcare may not fully internalize his or her role as “leader” on the team, but the responsibility inherent with licensure to practice, understand expectations and fulfilling them, is essential. Effective delegation is an important leadership strategy for any RN to learn and execute, as patient outcomes are ultimately tied to the RN assigned.
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