Incomplete EHR Health Record Content Review-explain to her the step process of how discharged patient records are picked up by the HIM discharge analyst, passed to the provider and so on until the record is completed and closed.

As an Assistant HIM Manager, it’s your responsibility to train all new HIM personnel. You have recently hired a new HIM Heath Record Analyst. She has HIM experience, but all her chart review experience has been on paper-based health records and not electronic. You are working with her on a patient admitted on 1/10 with the diagnosis of morbid obesity with an acute COPD exacerbation.

A pre-op anesthesia consultation was ordered on 1/11 due to the COPD. The surgical plan for this patient is to perform a weight reduction surgery on 1/14 after all lab results and consultations are posted and reviewed by Dr. Gordon. Surgery was conducted and was uneventful. After the patient was able to drink water, hold it down with soft food, and ambulate, the patient was discharged on 1/17. Today is 2/10. You two review the electronic record for Dr. Gordon’s patient and the documentation found in the record.

You go over the documentation guidelines for record completion at your facility with Jane. Remember Jane has no experience with EHRs only paper chart review so you need to explain to her the step process of how discharged patient records are picked up by the HIM discharge analyst, passed to the provider and so on until the record is completed and closed.

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