Shanholtzer 1e, Instructors’ Manual
Chapter 2
Chapter 2
Functions, Careers, and Credentials of the HI Processional: Documenting, Maintaining, and Managing Health Information, Past and Present
LESSON PLANS
Class Preparation: Teaching Focus and Resources
Chapter 2 discusses the importance of documentation by all users of health information. The development, job responsibilities, and educational opportunities of the Health Information Profession are addressed.
Learning Outcomes
2.1 Explain the importance of documentation needed by users of health information.
2.2 Categorize the job responsibilities of health information professionals.
2.3 Discuss the development of health information management as a profession.
2.4 Evaluate the educational opportunities and certifications of health information professionals.
Class Presentation
L.O. 2.1 Explain the importance of documentation needed by users of health information.
Slide 2-6 / · Documenting healthcareSlide 2-7 / · Paper vs. electronic records
Slide 2-8 / · Key differences between EMRs and EHRs
Slide 2-9 / · Users of health records
L.O. 2.2 Categorize the job responsibilities of health information professionals.
Slide 2-10 / · Traditional HIM functions in transitionSlides 2-11 - 2-14 / · Traditional HIM functions
L.O. 2.3 Discuss the development of health information management as a profession.
Slide 2-15 / · Timeline of the profession of health information managementSlide 2-16 / · HIM professional associations
L.O. 2.4 Evaluate the educational opportunities and certifications of health information professionals.
Slide 2-17 / · Education and certification of the health information professionalSummary Slides
Slide 2-18 / · Synopsis of the chapterTeaching Tips
- Review the differences between an electronic health record (EHR) and an electronic medical record (EMR).
- Review the advantages and disadvantages of using paper records vs. electronic records.
- Discuss why it is important to keep track of the location of paper health records and why this step is unnecessary in an electronic health record system.
- Discuss the importance of forming organizations such as AHIMA, HIMSS, AMIA, and AHDI of record clerks.
- Have the students access the website of AHIMA, HIMSS, AMIA, or AHDI and explain three benefits of belonging to a professional organization.
- Assign key terms as homework and then discuss as a whole group.
- Select one type of allied health professional to research. How would an HIM professional interact with this professional?
- Put students into small groups, and assign each group a set of terms to define and learn. Then have each group teach their set of terms to the rest of the class.
- Ask students whether any of the key terms are familiar to them already; use their responses to tie in the rest of the terms.
- At the end of the slides of key terms, ask the class to identify which ones they feel are most common and have a class discussion about the reasons.
- If the class has a writing assignment component or term project component, have the students select a key term about which to write a paper and/or PowerPoint presentation. Then have them present the information to the class.
- Complete the Thinking it Through exercises as the text is covered.
- Assign chapter review questions to be completed as a homework assignment or during class time.
- Chapter test questions are available in Connect.
ANSWER KEYS
Thinking it Through ANSWER KEY
LO 2.1:
1. Question: Explain the differences between an electronic health record (EHR) and an electronic medical record (EMR).
Answer: An EMR is a health record in digital format that is stored by an individual physician’s practice (or hospital); an EHR is also digital but is meant to be exchanged (shared) with other physician practices, such as specialists, and other hospitals as needed for the continuum of care.
Learning Outcome: 02.01
Feedback: Though used interchangeably, the EMR is a digital version of a paper medical record (chart) used by the physician’s office (or other healthcare facility) to care for the patient. An EHR is a compilation of health records for a patient from various healthcare facilities and ensures the exchange of health information in the continuum of care.
2. Question: What is discharge planning? At what point in a patient’s hospital stay should it begin? Which healthcare professionals assist with discharge planning?
Answer: Discharge planning begins as soon as a patient is admitted to the hospital. It is the process of preparing a patient to leave, and the case manager, care coordinator, and social worker are involved in discharge planning.
Learning Outcome: 02.01
Feedback: Discharge planning – preparing a patient to leave the hospital – begins as soon as a patient is admitted; the patient’s care coordinator, case manager and social worker (if applicable) are involved in discharge planning.
3. Question: Discuss three disadvantages of using paper records versus electronic records.
Answer: Communication, time, and expense are three disadvantages to using paper records.
Learning Outcome: 02.01
Feedback: Communication with external users, timeliness for patient care, and expense are all disadvantages to using paper records.
4. Question: Why is it important to keep track of the location of paper health records? Why is this step unnecessary in an electronic health record system?
Answer: At each moment of the day, an organization must be able to access every medical record in the facility. In an electronic environment, records can be readily accessed 24 hours per day by many individuals at the same time.
Learning Outcome: 02.01
Feedback: Outguides can be used to track paper records, but once the records have left the file room, they can be moved several times without documentation. Electronic records are also available.
LO 2.2:
1. Question: What is the difference between an incomplete health record and a delinquent health record? Where in the facility is the difference documented, and what is the definition based on?
Answer: An incomplete record is one that contains deficiencies that are identified during quantitative analysis. A delinquent record is one that is more than 30 days incomplete.
Learning Outcome: 02.02
Feedback: Examples of medical record deficiencies are reports that need to be dictated and clinical provider signatures that are identified during quantitative analysis. A delinquent record is a paper record that has remained incomplete or unrevised for more than 30 days.
2. Question: Why is it necessary to collect and report on data about cancer patients?
Answer: Cancer registries assist in research by providing valuable data about cancer patients’ quality of life, prognoses, treatments, successes, recurrences, and the like.
Learning Outcome: 02.02
Feedback: The data collected by cancer registries are used to further research and analyze current cancer treatment options.
3. Question: Celeste, a release of information coordinator, is responsible for information governance at her hospital. What additional job responsibilities would Celeste be asked to perform?
Answer: It means that Celeste is responsible for ensuring data is secure, accurate, and relevant. Basically, she is in charge of maintaining data and the security of that data.
Learning Outcome: 02.02
Feedback: Working in data governance, Celeste is ultimately in charge of ensuring the accuracy and security of all data collected at her hospital.
LO 2.3:
1. Question: What was the purpose of forming an organization of record clerks? Is it similar to the reason professional organizations are still prevalent to this day? Explain.
Answer: The first organization of record clerks was formed to promote the profession as well as to establish standards of education and continued learning for records professionals. Yes, it was formed for many of the same reasons present-day organizations exist – to promote and encourage quality within professional spheres.
Learning Outcome: 02.03
Feedback: The first professional organization for record clerks was founded for many of the same reasons current organizations exist – to promote and encourage quality within professional spheres.
2. Question: Why is it necessary for AHIMA and HIMSS to maintain a close alliance?
Answer: They must maintain a close alliance due to the overlapping nature of their goals – AHIMA’s of using healthcare data and HIMSS’s on the technology behind the data.
Learning Outcome: 02.03
Feedback: AHIMA and HIMSS must maintain a close alliance because of the close relationship between their purposes – using data (AHIMA) and using technology to maintain that data (HIMSS).
3. Question: Access the website of AHIMA, HIMSS, AMIA, or AHDI and explain three benefits of belonging to a professional organization.
Answer: Answers will vary, but students should show evidence of actually visiting these websites and their responses should show understanding of both website information and chapter concepts.
Learning Outcome: 02.03
Feedback: Your response should have touched on important ideas such as increasing knowledge in your chosen profession, proving to employers your dedication to your craft, and the like.
LO 2.4:
1. Question: What does the acronym CAHIIM stand for, and why would a prospective student seek to attend a CAHIIM-approved HIM program?
Answer: CAHIIM stands for the Commission on Accreditation for Health Informatics and Information Management Education. Graduates of a CAHIIM educational program are eligible to sit for AHIMA certification exams.
Learning Outcome: 02.04
Feedback: Prospective students desiring to earn AHIMA credentials after graduation should seek to enroll in CAHIIM accredited programs.
2. Question: Other than to maintain certification, what is the value of earning CEUs?
Answer: Students may mention that obtaining CEUs shows initiative to potential employers, allows them to remain current in their fields, and helps them obtain a competitive edge on their peers who may not hold as many CEUs.
Learning Outcome: 02.04
Feedback: The value of CEUs is that they allow one to gain a competitive edge in the field and shows potential employers a sense of initiative and drive.
3. Question: Explain how an associate degree would differ from a master’s degree regarding the graduate’s knowledge base and curriculum coverage.
Answer: Generally, an associate degree program would be more basic and reflect the probable lack of knowledge and experience among students, while a master’s curriculum would be more rigorous and assume a deeper level of experience and knowledge of its enrollees.
Learning Outcome: 02.04
Feedback: Typically, an associate program would be taken by people with little to no experience, so the curriculum would be broader and reflect that lack of experience; a master’s program would assume that learners were already active in their fields, so the curriculum would be more focused, rigorous, and demanding.
Chapter Review ANSWER KEY
Matching:
1. [LO 2.2] information security
Answer: d
2. [LO 2.2] coder
Answer: m
3. [LO 2.2] unit record
Answer: e
4. [LO 2.1] third-party payer
Answer: k
5. [LO 2.2] information governance
Answer: a
6. [LO 2.2] quantitative analysis
Answer: b
7. [LO 2.2] enterprise system
Answer: g
8. [LO 2.2] privacy officer
Answer: c
9. [LO 2.2] compliance officer
Answer: j
10. [LO 2.3] transcriptionist
Answer: n
11. [LO 2.2] eHealth management
Answer: f
12. [LO 2.2] release of information coordinator
Answer: i
13. [LO 2.1] outguide
Answer: l
14. [LO2.2] revenue cycle manager
Answer: h
Learning Outcome: 02.01, 02.02, 02.03, 02.04
Feedback: Learning key terms is essential to the field of health information management and technology.
Multiple Choice:
15. Question: A patient encounter is documented in the health record
Answer: c
Learning Outcome: 02.01
Feedback: Every time a patient is seen, the encounter is documented in the record.
16. Question: Which is true of facilities that use paper records?
Answer: d
Learning Outcome: 02.01
Feedback: Paper files are easily outdated or incomplete since the files can travel easily and updates are not necessarily made in real time.
17. Question: Health records must be kept in some format, at a minimum for
Answer: c
Learning Outcome: 02.01
Feedback: Patient records must be kept for a minimum of five years.
18. Question: Which person would be considered an allied health professional?
Answer: a
Learning Outcome: 02.02
Feedback: Lab technicians are considered allied health professionals.
19. Question: Incomplete records must be completed within days of an encounter or discharge.
Answer: c
Learning Outcome: 02.02
Feedback: Health records need to be completed and finalized within one month of an encounter.
20. Question: What is another term for scanning?
Answer: b
Learning Outcome: 02.02
Feedback: Imaging is another term for scanning.
21. Question: A public health official calls your office, asking for data regarding the incidence of pertussis in your patients. What department or staff member would most likely be responsible for responding to the official’s request?
Answer: a
Learning Outcome: 02.02
Feedback: The data governance department would respond to the public health official’s request.
22. Question: Which person would be considered a physician extender?
Answer: b
Learning Outcome: 02.03
Feedback: Physician extenders are providers of healthcare who have advanced education and can diagnose as well as give orders.
23. Question: A(n) is awarded to someone who has demonstrated advanced expertise in his or her field.
Answer: d
Learning Outcome: 02.04
Feedback: Earning professional certifications shows that someone has demonstrated expertise in their chosen field.
24. Question: Which professional certification currently has no restriction on degrees or years worked?
Answer: a
Learning Outcome: 02.04
Feedback: A Certified Healthcare Technology Specialist certification can be earned by someone who has no experience or degree in their area of work.
Short Answer:
25. Question: Describe the five main uses of a health record.
Answer: EHRs assist in the healthcare team’s communication; document a patient’s health status; protect patients and healthcare workers in legal matters; justify reimbursement; and provide documentation for coding and data gathering.
Learning Outcome: 02.01
Feedback: EHRs are used in the communications of healthcare teams, to document patient health status (and therefore the plan of care), for protecting patients and healthcare workers in legal matters, justifying reimbursement, and providing a basis for coding and data gathering.
26. Question: Why is handwriting a safety concern with paper records?
Answer: When records are maintained in paper format, illegible handwriting can cause serious issues with patient care and treatment. If providers and other healthcare professionals are not able to read documentation, they are likely to make mistakes when working with patients.