Assignment Problem:
Reference:
Brickner, M. 2020. Health Record Content and Documentation. Chapter 4 in Health Information Technology: An Applied Approach, 6th ed. N. B. Sayles and L. Gordon, eds. Chicago: AHIMA.
Case Scenario:
The emergency department (ED) chair has asked for a documentation audit of ED records. Your staff conducted the audit, the results of which were very poor. There was no consistency in the ED record documentation. You check the medical staff by-laws and realize that there are no specific guidelines related to ED documentation. The reports can be found in the HIM Case Study book.
Determine documentation requirements for ED reports. List them here.
Audit the five representative ED cases found in the case study book to determine the major areas in need of documentation improvement. As HIM director, present your results in a short memo to the ED department chair, Dr. Wilkerson.
The timing for this coincides with the transition of ED documentation into an electronic format. You propose to utilize the electronic record to facilitate the appropriate data collection. Create a screen design that encompasses the required ED documentation data elements.