As defined by AHIMA, health information management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information

vital to providing patient care. The healthcare manager plays a crucial role on the healthcare team. Health information management serves as the bridge

between the clinician and the patient’s healthcare information. Healthcare managers must possess clinical skills, management skills, and technical skills. The

final project will provide you the opportunity to demonstrate your expertise in each of these skill areas. Being an expert in analyzing and reporting vital health

information will set you apart from the rest in the HIM field.

The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality

final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.

In this assignment, you will demonstrate your mastery of the following course outcomes:

 Analyze health records for data components and use in professionally managing patient health

 Compile organization-wide health record documentation guidelines based on appropriate laws, standards, and regulations

 Analyze the utility of secondary data sources for the effective management of patient information

 Examine the use of technology for identifying effective data collection, storage, and reporting of health information options

Prompt

For the final project, you will imagine yourself as a HIM professional at New England North Hospital. You will begin by reviewing a medical record (see the HIM

200 Medical Record document, linked in the project assignment in Module Seven of your course), as well as the Joint Commission (E-dition) Standards. You will

then report on findings related to the hospital’s compliance with laws, standards, and regulations in regard to how health record documentation is collected,

stored, and eventually reported. In addition, you will analyze storage options for medical records and propose a recommendation for storage to enhance

disaster recovery and data security. You will also assess the performance of the computer systems.

To complete the project, you will use the information in the following scenario:

The New England North Hospital uses manual data entry for all clinical notes and vital signs. When a nurse or clinician enters the health record, he or she has to

manually enter the patient’s medical record number from the patient’s arm band. Workstations on wheels (WOW) are deployed to all clinical locations with

wireless communications to the main server, but the workstations need to be charged between uses and sometimes the nurse leaves the WOW plugged in in

the hallway, writes down vital signs for an inpatient, and charts the findings later. The healthcare information manager wants to automate some of the systems

with barcode readers, automatic data capture, and other tools to help reduce data entry errors.

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The system has a data center in a power-conditioned, protected room in the hospital with generators to maintain power. The healthcare information manager

is concerned that a large disaster such as a fire, flood, or explosion could destroy the room with its server and all the data. There are several options to

consider: keeping a backup in another section of the hospital, keeping a backup in a remote location, or using a cloud server instead of the data center. Of

course, a hybrid system using two or more of these options could be used, and each system has its pros and cons.

Clinicians have been asking for internet access at the point of care of their patients to use for patient education or to search for standards of care for unusual

cases. At this time, the hospital network is completely separate from the internet to preserve security, but it seems it is time to allow access to the internet. It

is up to the hospital information manager to present a plan to bring the internet into the hospital while maintaining a high level of security.

Specifically, the following critical elements must be addressed:

I. Analysis of Health Record: Examine the patient health record and answer the following questions:

A. Does the patient have a family history of diabetes? What report did you find this information on?

B. What procedure was performed?

C. Who was the surgeon?

D. What type of anesthesia was used?

E. What medications were prn (as needed)? What report did you find this information on?

II. TJC: In this section, you will review the Joint Commission (E-dition) Standards as they relate to the health record.

A. Identify the data TJC routinely reviews for compliance with Record of Care (RC) standards as listed in the TJC E-dition.

B. Evaluate where the record is complete and where it is missing data.

C. Based on the missing data, outline the TJC standards where the hospital is deficient and describe the content of each TJC standard that was

violated. How will these deficiencies impact compliance?

III. Secondary Data Sources: For this next section, you will examine the secondary data sources the hospital utilizes and report on your findings.

A. Explain how secondary data sources are created and how they are used to build local and national registries.

B. Evaluate what type of policy would ensure the required data elements are present in the patient record for data collecting registry purposes.

IV. Systems and Technology: In this section, you will examine and report on what technology is being used and how it is being used within the

organization.

A. Describe how the organization utilizes technology for collecting and storing data.

B. Describe the gaps or issues with functionality of the current collection and storage system(s).

C. Based on the identified gaps or issues, recommend types of technology and storage options that would serve the organization better. Be sure

to justify each recommendation.

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V. Conclusions and Recommendations: For the final section, you will compile your findings thus far, and make recommendations for the professional

management of patient health information within the organization.

A. Based on your audit of the medical health record, explain which data items are required for patient care and compliance with

requirements.

B. Based on your identification of TJC requirements for information management standards and quality measures, report your findings on the

organization’s compliance or noncompliance with such requirements.

C. Outline the compliance with a local and national registry from the secondary sources and its importance.

D. Make recommendations for any identified compliance deficiencies and defend your recommendations.

Milestones

Milestone One: Analysis of Health Record and Joint Commission

In Module Three, you will submit the analysis of the Joint Commission Record of Care and the Treatment Service Standards, and compose a description of

the standards, importance of compliance, and the deficiencies. This milestone will be graded with the Milestone One Rubric.

Milestone Two: Systems and Technology

In Module Five, you will submit the analysis of the systems and technology of the organization, including the system for collecting and storing data and

your recommendations for systems that might fill any gaps. This milestone will be graded with the Milestone Two Rubric.

Final Submission: Final Project

In Module Seven, you will complete your secondary sources and conclusions and recommendations sections of your final project and submit your completed

final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback

gained throughout the course. This submission will be graded with the Final Project Rubric.