Overview
Health information management (HIM) serves as the bridge between the clinician and the patient’s healthcare information. The healthcare manager plays a
crucial role on the healthcare team in collecting, analyzing, and protecting patient health information. This project will help you develop these skills.
The project is divided into two milestones and a final project. The milestones are due in Module Three and Module Five. Your instructor will give you feedback
on the milestones that you will use to produce the final version of your final project. The final project is due 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 Global Care Medical Center.
You will begin by reviewing a health record. Then, you will compare it to the Joint Commission (TJC) standards. You will then report on findings related to the
hospital’s compliance with laws, standards, and regulations regarding 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.
For more information on the parts of the project, review the Milestones section below.
For the final project, 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?
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II. TJC: In this section, you will review The Joint Commission (TJC) (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. 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.
IV. 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.
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
You will prepare for the final project by submitting two milestones in Modules Three and Five. These milestones consist of parts of the final project. After you
submit each milestone, you will receive feedback from the instructor, which you should incorporate into your submission of the final project in Module Seven
Milestone One: Analysis of Health Record and Joint Commission
In Module Three, you will evaluate the completeness and accuracy of a health record against The Joint Commission (E–dition) Standards (TJC). This
milestone covers the first two sections of your final project, Analysis of Health Record and TJC. It will be graded with the Milestone One Rubric.
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Milestone Two: Systems and Technology
In Module Five, you will look at the hospital’s technology setup and decide how to improve it. This milestone covers the section of your final project,
Systems and Technology. It will be graded with the Milestone Two Rubric.
Final Project
In Module Seven, you will complete the last two sections of your final project, Secondary Data Sources and Conclusions and Recommendations, and submit your
completed five–part project. It should be a complete, polished artifact containing all the critical elements of the final product listed in the rubric below. It should
also reflect the incorporation of instructor feedback gained throughout the course. This submission will be graded with the Final Project Rubric.
Final Project Rubric
Guidelines for Submission: Your final submission should be 6 to 8 pages in length (plus a cover page and references) and must be written in APA format. Use
double spacing, 12–point Times New Roman font, and one–inch margins. All references should be cited in APA