Overview: For the final project, you will imagine yourself as a HIM professional on their first day at a new job at New England North Hospital. The HIM director
has tasked you with completing a training exercise as part of your new job training. This exercise will provide practice for some of the tasks you will complete on
a daily basis. In the training exercise, you will begin by reviewing medical record, as well as the Joint Commission 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. The exercise will serve as a useful tool for developing the necessary skills required by a
HIM professional.
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.
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.
For this milestone, 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. Begin by using the Patient Health Record Quality Review document to evaluate the completeness
and accuracy of the provided medical health record. You will submit your completed checklist with your Milestone One paper.
Note: The Joint Commission has a large number of accreditation requirements. For this activity, you will visit the Joint Commission Standards page, where you
will focus on the “Information Management” and “Record of Care, Treatment, and Service” requirements listed under the “Accreditation Requirements.” See the
image below for guidance: