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
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
Buchbinder, S.B., Shanks. N. (2007). Introduction to healthcare management. Sudbury, Mass: Jones and Bartlett Publishers Inc.
In the medical billing and coding process there are several steps. In the medical billing process physicians prepare and sign documentation of the patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program and to prepare claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Claims that are correct help to reduce the chance of an investigation of the practice for fraud and also the risk of liability if an investigation does occur (Valerius, Bayes, Newby & Seggern, 2008). Most physicians depend on their personnel to process their medical bills without looking at the bills before they’re submitted for payment. Some physicians who don’t review the medical billing procedures may not receive the payment they deserve (Adams, Norman, & Burroughs, 2002).
It would be necessary for a hospital administrator to look closely at ways to lower healthcare costs and provide more efficient care when a large employer like BRPP states they are thinking of relocating their employee inpatient hospital services to a company like InduShealth. InduShealth is offering substantially lower prices for several surgical procedures and a U.S. hospital administrator would not want to lose this large consumer population if it was possible to find more efficient methods of providing healthcare to their patients (McLaughlin & McLaughlin, 2008). One pricing strategy that a hospital administrator could advocate for is a bundled...
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
A nurse manager plays an important role on a hospital unit. Evans defines the role of a nurse manager as one who makes sure all the needs required on a daily basis are accomplished (Evans, 2011). Evans goes on to say that one primary responsibility of a nurse manager acting in the position of a leader is to “raise the level of expectation and help employees reach their highest level of potential excellence” (Evans, 2011). With this said, it is important to identify potential barriers and problems that a nurse manager would face on a given unit and create or adopt evidence-based interventions to eliminate these problems. When this is accomplished, it will help to foster a work environment that maintains safety to patients as well as staff.
Hospital administrators will charge nurse leaders with ensuring that patient positive outcomes prevail while also controlling overhead. Nurse leaders are specially trained just for this task. Clinical Nurse Leaders are the experts that America’s patients will rely on to keep them safe and healthy in hospital settings.
The focus of this paper is to explore the role of the registered nurse as a leader and manager in the healthcare team. The role of management in nursing affects almost every aspect of the registered nurse’s daily work. An effective manager requires a variety of interpersonal skills that are both learned and intuitive. These skills are of great importance in the management of clients, family, and other healthcare professionals. Management skills are both learned and intuitive, although practice and experience may be one of the most essential ingredients to effective management. This paper explores a few of the essential skills required to be an effective manager.
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.
While HIE has been more than twenty years in the making, it has only recently gained the majority of its support. This is because, until the recent years, HIE success has been marginal when compared to its failures and shortcomings. HIE generally started in 1990 when the Hartford Foundation began its CHMIS initiative. The was the "Community Health Management Information System" that got its start from grants to several states and cities. CHMIS provided a point of reference for data to be collected and maintained. This data provided information on demographics, clinical data, and information divided geographically. CHMIS targeted data for the stakeholders who were the primary consumers and benefactors of the data assessments. Another function of CHMIS was to facilitate billing and determine patient eligibility for cost reductions, making CHMIS a transaction system. (J Am Med Inform Assoc, 2010 )
A person needs to be able to document numerous amounts of information in a neat and organized manner in the most accurate way possible. A nurse in the field needs to be able to organize medical records and provide the information needed to help improve the quality of health care to the patients. For providing the health care personnel with accurate information is important to delivering quality care to the patients and improve job performance of other nurses, doctors and other medical staff and
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.
My overall vision is to develop and promote information technology solutions to better improve health outcomes, patient safety, and prevention of medical errors in underserved countries. In closing, Health informatics and Health Information Management is an exciting program that is designed to provide me with a suite of resources to help me develop essential leadership, teamwork, and healthcare management skills that will help me to become successful leader in healthcare
... understand where and how each statistic is coming from. Health records are the primary source of data used in compiling health care statistics. The health record staff, therefore, may be responsible for .When a person gains this knowledge this allows for an Administrator are fully be able to make the proper changes in the healthcare organization that will end with the best effective and successful solution.
...ransformation. However, the power to improve the current regulatory, business, and organizational conditions does not rest solely with nurses; government, businesses, health care organizations, professional associations, and the insurance industry all must play a role. Working together, these many diverse parties can help ensure that the health care system provides seamless, affordable, quality care that is accessible to all and leads to improved health outcomes. Also, the Nurse leader provides the link between management and the frontline staff who personally interact with the public and patients. They are the interface between management and care delivery, and can only be effective if they have the support, time, authority, and respect necessary to competently and visibly lead their teams on the delivery of high-quality care. (Dawes, M., Davies, P., T., 2006).