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Electronic Record-Keeping in Healthcare

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Electronic Record-Keeping in Healthcare

topic : Electronic Record-Keeping in Healthcare

Assignment Description:

Electronic Record-Keeping in Healthcare

For this week’s assignment you will be taking an inventory of the information systems in your organization. To complete the assignment, you might need to contact other departments. Based on what you have learned so far in this course, create a 15-20 slide PowerPoint presentation that addresses each of the following points/questions. Be sure to completely answer all the questions for each bullet point. Use clear headings that allow your professor to know which bullet you are addressing on the slides in your presentation. Support your content with at least three (3) scholarly citations using APA citations throughout your presentation. Make sure to reference the citations using the APA writing style for the presentation. Include a slide for your references at the end. Follow best practices for PowerPoint presentations related to text size, color, images, effects, wordiness, and multimedia enhancements. Review the rubric criteria for this assignment.

1. Differentiate between electronic health record (EHR), electronic medical record (EMR), and personal health record (PHR)

2. Differentiate between clinical information systems (CIS) and administrative information systems (AIS)

3. What systems are currently being utilized at your organization?

4. If you had to rate the information-technology status of your organization, what score would you give them?

5. Identify two strength and two weaknesses of the current information-technology being used.

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Electronic Health Record Coder

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Electronic Health Record Coder

Title: Electronic Health Record Coder

As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a provider. You will ensure the accuracy and integrity of the codes that are used. Additionally, you will review each medical record for compliance purposes and report issues that may be apparent. When there is a question, you will ask or query your provider to confirm that the medical record supports the code selection. It really begins with the medical coder as they are the gatekeepers or coding accuracy and complian

Include the following aspects in the assignment:

· Describe what you feel a day may be like once you become a coder

· What do you think will be most challenging?

· Summarize why it is essential to collaborate with clinical staff (MDs/APRNs) to resolve coding questions/discrepancies· Provide an example of a time when it may be necessary to query a physician.

 

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  A (4) B (3) C (2) D/F (1/0)
Focus: Purpose Purpose is clear Shows awareness of purpose Shows limited awareness of purpose No awareness
Main idea Clearly presents a There is a main idea Vague sense of a No main idea
  main idea and supported throughout main idea, weakly  
  supports it most of the paper. supported  
  throughout the   throughout the  
  paper.   paper.  
Organization: Well-planned and Good overall There is a sense of No sense of
Overall well-thought out. organization, includes organization, organization
  Includes title, the main although some of the  
  introduction, organizational tools. organizational tools  
  statement of main   are used weakly or  
  idea, transitions and   missing  
  conclusion.      
Organization: All paragraphs have Most paragraphs have Some paragraphs Para. lack clear ideas
Paragraphs clear ideas, are clear ideas, are have clear ideas,  
  supported with supported with some support from  
  examples and have examples and have examples may be  
  smooth transitions. transitions. missing and  
      transitions are weak.  
Content Exceptionally well- Well-presented and Content is sound and Content is not sound
  presented and argued; ideas are solid; ideas are  
  argued; ideas are detailed, developed present but not  
  detailed, well- and supported with particularly  
  developed, evidence and details, developed or  
  supported with mostly specific. supported; some  
  specific evidence &   evidence, but  
  facts, as well as   usually of a  
  examples and   generalized nature.  
  specific details.      
Research (if Sources are Sources are well Sources support The paper does not
assignment exceptionally well- integrated and some claims made in use adequate
includes a integrated and they support the paper’s the paper, but might research or if it does,
research support claims claims. There may be not be integrated the sources are not
component) argued in the paper occasional errors, but well within the integrated well.
  very effectively. the sources and paper’s argument. They are not cited
  Quotations and Works Cited conform There may be a few correctly according
  Works Cited to MLA style sheet. errors in MLA to MLA style, nor
  conform to MLA   style.. listed correctly on
  style sheet.     the Works Cited
        page.
Style: Sentence Sentences are clear Sentences are clear Sentences are Sentences aren’t
structure and varied in but may lack generally clear but clear
  pattern, from simple variation; a few may may have awkward  
  to complex, with be awkward and there structure or unclear  
  excellent use of may be a few content; there may  
  punctuation. punctuation errors. be patterns of  

Electronic Health Record CoderElectronic Health Record Coder.

 

 
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