HIT272 practicum objectives

Portfolio Practicum Objectives

Health Information Practicum Capstone

Vicky Fomby

DeVry University

Rose Dennis

19.04.2023

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Practicum Objective 1

Identify facility standards regarding healthcare documentation.

Northeast Alabama Regional Medical Centre has created guidelines for recording patient

encounters in primary care settings. Maintaining up-to-date, comprehensive, and well-organized

records is essential for ensuring smooth communication, coordination, and continuity of

care(American Psychiatric Association 2017). The medical record’s privacy, accessibility, and

needed information are all addressed in the guidelines. Northeast Alabama Regional medical

center mandates secure medical record keeping to protect the privacy of its members. Access to

records should be restricted to those who need it while yet being simple for users. Furthermore,

employees are anticipated to undergo education on member privacy. As part of our Quality

Improvement Program, we will ensure that the new guidelines are followed.

The outpatient department is typically linked with the inpatient services and is staffed by

consultant doctors and surgeons. This makes the outpatient department an essential component of

the hospital. It is situated on the bottom level of the medical center, close to the parking garage,

and it provides wheelchairs and stretchers for patients who are unable to walk independently.

Patients and their families can access various amenities, including restrooms, public telephones,

coffee or snack bar, water dispensers, gift shops, florists, and quiet rooms. This multitasking in

the department has done the work in the department more, and insufficient workers may cause

overworking of the nurses. In my practicum, the department has more workers, which do help the

inpatient department to perform its duties.

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Practicum Objective 2:

Perform ten chart audits and identify all deficiencies.

Chart Audit Tool (Sample)

Instructions: You may use this as a chart audit tool for P.O. #2. Update based on your facility’s

documentation requirements.

M.R. #
Date of

Admission

Date blocked out

Date of

Discharge

Date blocked out

Disposition Discharged home

Document Completed Comments
History and Physical

Chief Complaint Y
Present Illness Y

Past Medical History Y
Past Social History Y

Past Family History Y
Review of Systems Y
General Condition Y

Vital Signs Y
Body Systems and Parts: Y

Diagnosis(is) Y
Signed Y

Signed w/in 24 hours Y Presumed
Physician Orders

Present Y
Signed Y

Signed w/in 24 hours Y Presumed
Physician Progress Notes

1 per day Y
Signed Y

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Nursing Notes
1 per shift (3 per day) Y

Signed Y
Diagnostic and Therapeutic

Procedure Reports

Present per Physician’s Order N/A
Signed

Surgical Procedure

Documentation

Y

Anesthesia Report
Present Y
Signed N “encounter closed”, but no

indication of an electronic

signature
Operative Report

Present Y
Signed Y

Recovery Room Report
Present N Unable to locate in the

document
Signed

Intake and Output
Present N/A
Signed N/A

Medication Administration
Present N/A
Signed N/A

Discharge Summary
Present Y
Signed Y

Discharge Instructions
Present Y
Signed Y

Consent to Treatment
Present N Unable to locate in the

document
Signed

Other
Consultation Notes

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Present Y
Signed Y

Practicum Objective 3

Perform an analysis of one predetermined data element.

The number of errors found:

Email not transferred 1

3

Marital status not selected

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3

Missing/ incorrect address information

1

4

Sex not selected
4

Insurance information not entered

1

5

Patient release of information contacts did not enter

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During the process of revising the patient’s medical records, the information was

discovered. As a result, throughout the auditing process, my practicum was required to conduct

follow-up interviews with the patients whose medical records were incomplete to collect the

necessary information to ensure patient safety.

When I was performing my data analysis at my workplace, I had to make sure that I

adhered to The medical record’s privacy, accessibility, and that needed information, are

adequately handled as mentioned in the standards. The data analysis for my data transfer project

was documented over five practicum days(American Psychiatric Association 2017). I was

looking at the patient data on the very first day, and according to the patient records that I

acquired, it was found that the number of patients kept on growing from one day to the next; this

gave rise to the possibility that there was an epidemic of a particular disease in the community.

My internship required that we provide specific recommendations that should be carried

out. It was clear from the activity log for the previous five days at the office that thirteen patients

who had been to the hospital had not reported their visits, and their emails had not been

forwarded to the appropriate division so that insurance bill revisions could be made.83 of the

patients who had been seen at the practicum did not provide information on their marital status.

Because of this, they could not receive payment for their outstanding medical expenses.

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Practicum Objective 4

Practicum Objective 5:

Perform a summary of data entry

Data entry is a subset of clerical work that entails entering information into

computers by any means necessary, including but not limited to typing and voice

recording. Our organization is well equipped with modern electronic computers and

experts who are also nurses record all the patient’s details. As I stated earlier, our

documentation is kept intact to ensure they are provided whenever asked. Data

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30%0% 5% 10 15% 20% 25% % 35% 40 %

Email not transferred

Marital status not selected

Missing/ incorrect address information

Sex not selected

Insurance information not entered

Patient release of information contacts not
Entered

Name incorrect

Phone number incorrect

Percentage of Error Occurrence

governance (D.G.) ensures that data in enterprise systems is available, usable, correct,

and safe. Effective data governance ensures that data is always the same, can be trusted,

and is not used in destructive ways.

A well-made data governance program usually has a governance team, a steering

committee, and a group of data stewards. Good data governance helps ensure that data in

different systems is consistent, which can affect how well B.I., enterprise reporting, and

analytics applications work. During my work time in the practicum, it took me approximately

10 minutes to go through the data and understand it better, which made me come up with

straightforward suggestions to improve the training.

Practicum objective 6.

A Performed an evaluation on facility documentation compliance. Creating the patient in

T.N. set up an account with additional interface tabs for me to add more knowledge on

transferring this data from one entry to another. The transfer of EHR data was a perfect project

for me as I could analyze data well. I used EHP to determine who needed help and developed a

“video visit technical risk score(American Psychiatric Association 2017). I started a pilot project

at three outpatient offices to see how well the rating system worked. Patients whose scores

showed they could use help got three text texts before their planned virtual visit. Some of the

patients could understand the technology better because of the test, and the health system staff

could improve their processes for enrolling patients in a telehealth program because of it.

Researchers suggested making things that would help patients when they went on instead of

before they did.

Insurance information came next. Specific plans were set up with billing code numbers.

The billing process might need to be clarified, but Northeast Alabama Regional Medical Centre

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has materials to assist parents and guardians in understanding it. Learn about the insurance

policies accepted by the facility, the cost of care, how to apply for and get financial aid, and how

patients could settle their accounts in this area. Some health insurance companies need patients

to provide their medical records with a reference or permission before providing coverage which

I had to attach for my patients. Parents may need to submit paperwork before or bring it with

them to their child’s checkup. I assisted Patients, and their families who needed help paying for

medical care can get it, and there are also options for interest-free payments. I also worked

closely with them to make sure that I made detailed breakdowns for patients who made their

payments online and updated their payment records.

UNITED HEALTH ORGANIZATION FRAUD, ABUSE AND WASTE POLICY MANUAL

Reason for Policy

United Health Organization (UHO) is committed to an environment fostering integrity

and trust for our patients, partners and the whole community. It was recognized that since 1997,

the Health Care Fraud and Abuse Control Program (HCFAC) has been at the forefront of the

fight against healthcare fraud, waste, and abuse.

Policy Statement

It was realized that in F.Y. 2016, the government recovered over $3.3 billion from

healthcare fraud judgments, settlements, and other administrative impositions. The Medicare

Fraud Strike Force has charged over 3,018 people with more than $10.8 billion in fraud, resulting

in a nationwide healthcare fraud takedown.

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Coding Resources.

These resources help Northeast Alabama Regional Medical Centre academics, staff, and

students find internal and external resources and policies and preserve the Northeast Alabama

Regional medical center brand. They include branding and name requests, conflict of interest,

email signatures, institutional review boards, Digital Signage Messaging System, IROC,

Overview Presentations, Video Services, Full-Time Faculty Gold Book, Part-Time Faculty Blue

Book, Copyright Compliance Policy, Photography and Film Rights, Use of Name & Visual

Brand Guidelines, CPN, Solicitation and Distribution Policy, Policy on Industry Interaction, and

Writing and Style Guidelines.

Scope

This policy covers all Regional Medical Centre product lines, including Priority Partners

MCO, Employer Health Programs, U.S. Family Health Plan, Regional Medical Centre Elder

Plus, and Regional center Health Advantage, Inc.’s Medicare Advantage and other commercial

insurance plans. Northeast Alabama Regional medical center plan providers, subscribers,

beneficiaries, members, staff, and subcontractors can report fraud and abuse.

Definitions

Fraud and abuse occur when someone intentionally deceives or misrepresents to get an

illegal benefit. False claims include billing for operations not performed, violation of another

law, fabricating medical record information, medically unnecessary services, non-covered

services, and inappropriate quality of service. Employees of the United Health Organization will

not engage in any actions which would result in fraud, abuse, or waste. The Health Insurance

Portability and Accountability Act of 1996 mandates that the Attorney General and Secretary of

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Health and Human Services create a Health Care Fraud and Abuse Control Program to

coordinate Federal, State, and local law enforcement programs, carry out audits, evaluations, and

inspections, make it easier to enforce civil, criminal, and administrative laws, and offer industry

guidance.

Term Definition
Abuse It is an action that goes against accepted good financial, business,

or medical practices and leads to an unnecessary cost or payment

for services that aren’t medically necessary or don’t meet the

standards for health care set by professionals.
Fraud Wrongdoing or breaking the law to make money or get something

else.
OIG Office of inspector general
Unbundling Unbundling means using different CPT codes for other parts of a

process, either because of a mistake or to get paid more.
Upcoding Upcoding” happens when a health care provider sends Medicare,

Medicaid, or private insurer’s codes for more important (and

more expensive) diagnoses or treatments than the provider

actually made or did.
Waste Microorganisms that can cause illness can be found in healthcare

waste. These microorganisms can infect medical patients, health

workers, and the general public.

Name Title Date

Practicum Objective 7

Perform and Recommend one health information system.

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An implication made to me was that the old EHR system did not have cloud back, so a

means to replace it was to be implemented. Patients’ Records were to be recorded manually due

to the electronic system’s failure, and some patients’ records needed to be more literate; hence, it

was a disadvantage for them to use the electronic system.

Upon reviewing different system options available for behavioral health providers, I finally

came up with a decision that Northeast Alabama Regional Medical Centre needed to come up

with a Prescription monitoring program was which required in I.L. Prescription drug monitoring

programs (PDMPs) are promising state-level treatments for opioid prescribing, clinical practice,

and patient safety. This system has an electronic database that tracks prohibited substance

prescriptions in a state and can give timely information regarding prescribing and patient actions

that contribute to the pandemic(American Psychiatric Association ,2001). They are universal and

require clinicians to consult a form of PDMP before prescribing prohibited medications in certain

instances. State health authorities employ PDMPs to analyze the pandemic, inform and assess

initiatives, and provide “proactive” reports to authorized users to safeguard high-risk patients and

identify inappropriate prescribing trends. States have made PDMPs easier to use and access, and

state-level evaluation can help identify and apply good practices.

Lab integration with ICANotes is primarily set up with their specific organizations, but

the ICANotes software program is for mental health clinics that allow for simple, one-click

narrative charting(American Psychiatric Association ,2017). It is hosted in the cloud and works

well for primary mental health facilities. Fast, narrative, and patient-specific are the hallmarks of

ICANotes clinical notes. Each generated message can be automatically coded to its highest

possible E/M service code that can be reimbursed.

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In my practicum, we decided to use lab integration to improve the patient information about

laboratory testing and procedures. Laboratory information systems are used in hematology,

chemistry, immunology, microbiology, toxicology, public health, and other laboratory areas to

organize the workflow and quality control of inpatient and outpatient medical tests. During a

provider visit, the laboratory information system will record, store, and update clinical details

about a patient at Northeast Alabama Regional Medical Centre.

Practicum Objective 8:

Identify a problem and provide a technology solution

The office contains prescription pads and susceptible-natured papered patient records,

which were recorded and kept openly, something which turned me off. From the exposure, it was

noticed that whenever a patient visited the office, it could take some time to trace their record,

and this issue was to be addressed with immediate effects. There were also long queues resulting

from a delay in the search for patient documents, and I came up with an electronic recording of

patients through a database.

My recommendation for a security system is to start with improved locks throughout. Keep

an eye on system access.

Healthcare providers should track who has access to their systems and use two-factor

authentication for all patient web accounts to reduce the risk of security breaches. This can be

done by putting policies in place in their area, such as policies to ensure that everyone who uses

the system is allowed to be there. Additionally, healthcare providers should use customer portals

to give patients access to their health information from anywhere, which can be a security risk

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for those who want to get in from the outside. Two-factor authentication is a great way to reduce

this risk and make the back end more secure.

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Signed Activity LogStudents are required to spend a minimum of 80 hours at their practicum

site during the current term/semester. The CO Activity Log must be completed in its entirety and

demonstrate specific practicum activities related to the course COs.

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This verifies that the above activities are accurate and reflect actual time spent
at the practicum conducting HIM activities. The onsite practicum director has
discussed this evaluation with the student. Actual signatures are required to
validate above.

Student
Signature

Practicum

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Director Signature

References

American Psychiatric Association. (2017, May). Resource Document on Psychotherapy Notes

Provision of the Health Insurance Portability and Accountability Act (HIPAA) Privacy

Rule. Retrieved from

%20Library/Psychiatrists/Directories/Library-and-

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/3

Archive/resource_documents/rd2002_PsychotherapyNotesHIPAA.pdf

Department of Health and Human Services Office for Civil Rights. (N.D.). HIPAA Privacy Rule

and Sharing Information Related to Mental Health. Retrieved from HHS.gov:

tomental-health.pdf

National Council for Behavioral Health. (N.D.). Behavioral Health I.T.: the Foundation for

Coordinated Care. Retrieved from

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