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HEALTH INFORMATION PRACTICUM II – HIT-231-1024

Professional Practice Experience

University of Maryland

Under the supervision of: Michael Putkovich, RHIA - Vice President

Eileen Austin, RHIA - Senior Manager

Nkechi Odukwe, RHIA – Manager

Shaivonne Brown – DIA Team Lead

Latoya Pratt – DAS Team Lead

Table of Contents

1. Introduction (Cover Page)

2. Day 1 - March 10, 2025 (Remote): Introduction to HIM Department Page 4-5

3. Day 2 & 3 - March 12–13, 2025 (Onsite): HIM Operations Page 5-7

4. Day 4 - March 17, 2025 (Remote): Epic Deficiency Tracking Module Page 7-8

5. Day 5 - March 18, 2025 (Remote): HIM Best Practice / Standard Work Page 8-9

6. Day 5 - March 18, 2025 (Remote): EHR Reporting Page 9-11

7. Day 6 - March 19, 2025 (Remote): Leadership Meeting Page 11-12

8. Day 7 - March 21, 2025 (Remote): Outpatient Coding Page 13-14

9. Day 7 - March 21, 2025 (Remote): Inpatient Coding Page 14-16

10. Day 7 - March 21, 2025 (Remote): Clinical Documentation Improvement (CDI) Page 16-17

11. Day 8 - March 24, 2025 (Onsite): Data Integrity and Chart Correction Page 17-18

12. Conclusion / Summary of Clinical Experience Page 18-19

13. Student Evaluation Questions Page 20

14. Appendix Page 21-30

Day 1 - March 10, 2025 (Remote) Introduction

My first day at the  Health Information Management (HIM) Department at the  University of Maryland Medical System (UMMS) was an insightful experience, setting the foundation for my practicum clinical. The day began with introductions to key leaders within the department, including:

· Michael Putkovich, RHIA – Vice President of HIM

· Eileen Austin, RHIA – Senior Manager

· Nkechi Odukwe, RHIA – Manager

· Latoya Pratt – DAS Team Lead

· Shaivonne Brown – DIA Team Lead

Following introductions, we reviewed the  HIM department pillars, organizational chart, and departmental functions to gain a clearer understanding of the structure and workflow within HIM. This helped to establish a solid foundation for comprehending how the department operates within the hospital system.

Next, we  validated confidentiality agreements, ensuring that all practicum participants understood the importance of safeguarding patient health information in compliance with HIPAA regulations and hospital policies. This session underscored the significance of data integrity and security in health information management.

We then moved on to an in-depth  review of the Enterprise Master Patient Index (EMPI) & Data Integrity (DI) pillars and functions. This provided valuable insight into how patient records are maintained, ensuring accuracy, consistency, and completeness in electronic health records (EHRs).

The final session of the day focused on  HIM Regulatory Compliance, which covered essential aspects such as:

· Document Auditing Specialist (DAS) Functions – Reviewing documentation for compliance with  The Joint Commission (TJC), CMS regulations, and hospital policies.

· Understanding the auditing process – Assessing records for accuracy, timeliness, and completeness in patient care documentation.

· Observing the reporting process – Learning how compliance data is utilized for hospital quality improvement initiatives.

This first day provided a comprehensive introduction to the HIM Department, its key functions, and the crucial role it plays in  ensuring data integrity, regulatory compliance, and the overall quality of healthcare delivery.

Day 2 &3 - March 12-13, 2025 (Onsite) HIM Operations

During my onsite practicum experience at UM Rehab (University of Maryland Rehabilitation and Orthopedic Institute), I had the opportunity to participate in a comprehensive review of the Health Information Management (HIM) Operations pillars and functions under the guidance of Kim Harris-Casher, HIM Site Manager.

The objective of these two days was to obtain in-depth knowledge of key HIM Operations processes, workflows, and departmental responsibilities. The experience provided valuable insight into the vital role HIM plays in ensuring the accuracy, accessibility, and completeness of patient health records.

Key Activities and Learning Points:

· HIM Operations Overview: I reviewed the core pillars and workflows of HIM Operations, including patient record management, imaging processes, chart completion, and archival procedures. This provided a strong foundation for understanding daily HIM departmental functions.

· Chart Retrieval Process: I observed how physical and electronic health records are received, logged, and tracked into the HIM department. This process ensures that all patient documentation is properly accounted for and readily accessible for clinical and administrative purposes.

· Imaging Process – Prepping, Scanning, and Indexing: I learned the detailed steps involved in prepping charts for scanning, ensuring documents are organized, free of duplicates, and properly labeled. After scanning, I observed the quality control and indexing processes that ensure scanned images are accurately categorized and stored within the electronic health record (EHR) system.

· Archives and Research Requests: I gained general knowledge of offsite storage management procedures, including how older or inactive patient records are stored, requested, and retrieved for research or clinical purposes.

· Chart Completion and Analysis: I participated in reviewing charts for completeness, identifying missing documentation, and learning the notification process used to inform providers of incomplete or delinquent records. Understanding the importance of timely and complete charting emphasized the HIM department’s critical role in regulatory compliance and hospital operations.

This onsite experience reinforced the importance of attention to detail, organization, and strong communication between HIM, clinical staff, and external storage vendors. Each function within HIM Operations supports patient care continuity, compliance with The Joint Commission (TJC) and CMS regulations, and ensures accurate recordkeeping for legal and financial purposes. The hands-on exposure to the full cycle of chart management deepened my appreciation for the behind-the-scenes work that enables hospitals to maintain efficient and compliant health information systems.

Day 4 - March 17, 2025 (Remote) Epic Deficiency Tracking Module

During my clinical practicum at UMMS HIM, I was introduced to Epic’s Deficiency Tracking Module, led by Karen Cosby, HIM Principal Trainer. The module ensures timely completion of clinical documentation critical for patient care, compliance, and billing. We covered how deficiencies are flagged, assigned, and resolved, emphasizing HIM’s role in provider education and collaboration with coders and compliance officers.

Key takeaways included:

· Identifying and tracking outstanding deficiencies.

· Assigning deficiencies to providers and ensuring timely completion.

· Investigating provider-declined deficiencies and escalating unresolved issues when necessary.

Through hands-on experience, I navigated the Epic system, reviewed deficiency workflows, and observed how HIM analysts work closely with providers to maintain documentation integrity.

HIM Operations: Reporting & Workflows (Remote Session)

A remote session covered Epic’s reporting capabilities for tracking deficiencies and optimizing workflows. We explored various work queues, including unassigned deficiencies, provider-declined deficiencies, and aged deficiencies. The session highlighted the challenges of provider reluctance, the role of deficiency analysts in ensuring compliance, and the importance of interdepartmental collaboration across HIM, coding, and compliance teams.

I also gained insight into how HIM reporting supports operational efficiency, helping teams prioritize deficiencies that may impact billing, reimbursement, and regulatory compliance.

Day 5 - March 18, 2025 (Remote) HIM Best Practice/Standard Work

During my clinical practicum at the UMMS Health Information Management (HIM) department, I had the opportunity to learn about best practices and standardized workflows in HIM operations. Led by Kyrston Jones, an EHR Analyst, this session provided a structured understanding of how HIM professionals streamline documentation processes, maintain compliance, and improve efficiency.

Key Learning Points

1. Document Preparation & Organization

· Discarding unnecessary documents, such as scanned duplicates and unsigned preliminary reports.

· Ensuring patient identifiers and service dates are accurate.

· Grouping and organizing documents by type and date for structured storage.

2. Batch Scanning & Workflow Optimization

· Understanding batch scanning procedures, including document classification and indexing.

· Utilizing tools like Unity Client for efficient scanning and tracking.

· Importance of properly labeling and preparing documents to prevent scanning errors.

3. Standardizing HIM Workflows

· Implementing best practices to ensure uniform documentation across UMMS facilities.

· Following protocols for document reconciliation, indexing, and quality assurance.

· Ensuring compliance with HIM policies to support regulatory requirements and hospital operations.

Day 5 - March 18, 2025 (Remote) EHR Reporting

During my clinical practicum in the UMMS HIM department, I participated in a session led by John Bumbray, a Reporting Analyst. This session focused on the role of data reporting in healthcare, including how reporting tools support quality improvement, compliance, and operational efficiency.

Key Learning Points

Role of Data Reporting in HIM

· Reporting tools help track deficiencies, compliance trends, and hospital performance.

· Data integrity is essential, as reports influence decision-making at executive levels.

· Ensuring that reports align with HIPAA guidelines and are securely shared only with authorized personnel.

Generating & Interpreting Reports

· HIM reports include dashboards, charts, and performance metrics used for decision-making.

· Understanding how to verify data accuracy before submitting reports to leadership.

· The importance of tailoring reports to user needs, as initial requests may not always reflect actual requirements.

Reporting Tools & Software Used

· Epic – Primary source for pulling hospital data across multiple facilities.

· Tableau, Excel (Pivot Tables/Charts), and BI Launchpad – Used for visualizing and analyzing trends.

· Vizio & PowerPoint – Essential for presenting data in a structured, digestible format.

This practicum session provided an in-depth understanding of how data reporting plays a vital role in HIM operations. I gained insight into how reports are generated, validated, and used for compliance and performance tracking. The session emphasized the importance of accuracy, as incorrect data can lead to significant operational challenges.

Additionally, I learned that reporting analysts must be proactive and detail-oriented, often needing to clarify report requests to ensure they meet end-user expectations. The ability to work independently and troubleshoot issues is a critical skill in this role.

Day 6 - March 19, 2025 (Remote) Leadership Meeting

I attended the University of Maryland Medical System (UMMS) Health Information Management (HIM) Leadership Meeting via Webex. This meeting provided valuable insights into ongoing operational challenges, new initiatives, and leadership strategies within the HIM department.

The session began with updates on staffing and recruitment, introducing a new HR partner, Metasource Hardware. Key topics discussed included the importance of ensuring that documentation processes align with minimum necessary requirements for patient information, and the plan to standardize documentation practices across departments.

There was a detailed discussion about the RCA Team Meeting update and upcoming SCORE results, which were postponed until April 1st. We reviewed the Psychological Safety Index (PS Index) reporting to assess team dynamics and operational challenges. One major focus was improving the turnaround time for documentation completion, particularly regarding coding-critical data elements necessary for billing processes. Leadership emphasized the need for providers to complete essential documentation within four days post-discharge, shifting away from the traditional 30-day expectation to expedite billing and reduce accounts receivable (AR) delays.

Additionally, we discussed upcoming training initiatives to support these changes, including voiceover trainings and policy revisions to help providers and HIM staff adapt to new documentation standards. Concerns about record deficiencies, pending documentation, and how these delays impact both coding and compliance were also addressed.

Another important area of focus was the management of pending and appended notes within the EHR. Strategies to track and address incomplete documentation without overwhelming staff resources were proposed. Leadership emphasized the need for a collaborative, system-wide effort to support timely documentation practices and improve overall operational efficiency.

The meeting also touched on upcoming department celebrations, the importance of maintaining work-life balance, and scheduling for the next HIM Department retreat.

Key Takeaways:

· New HR recruitment initiatives through Metasource Hardware

· Focus on timely completion of critical coding elements within four days post-discharge

· Upcoming training modules for documentation policy changes

· Improvements to PS Index scores with a focus on challenge safety

· Strategies for managing pending and appended notes more effectively

· Emphasis on teamwork, communication, and leadership engagement to drive operational improvements

Overall, today’s HIM Leadership Meeting offered a comprehensive look into the future direction of HIM operations at UMMS, highlighting the importance of adapting to new documentation standards and continuing to foster a culture of safety, compliance, and collaboration.

Day 7 - March 21, 2025 (Remote) Outpatient Coding

Today, I participated in outpatient coding activities where I observed and practiced retrieving and coding patient records using Epic and 3M 360 software. The focus was on coding Emergency Department (ED) charts, Same-Day Surgeries, and outpatient procedures. I learned how the 3M software assists coders by auto-suggesting ICD-10 and CPT codes, improving both efficiency and accuracy, while still requiring coder review and judgment for final code assignment.

In addition to coding diagnoses and procedures, I learned how to abstract critical elements such as the surgeon’s name and the date of surgery, which are essential for proper CPT coding and billing. Coders have access to a variety of reference tools integrated into 3M, including Coding Clinics, CPT Assistant, Anatomy references, medical dictionaries, and drug manuals, supporting accurate code selection and documentation.

We discussed how the coding team uses Microsoft Teams and WebEx for communication, screen sharing, coding huddles, and quick meetings, especially since the team operates in a mostly remote environment. I learned about the team’s productivity tracking system where coders log their daily productivity numbers (charts coded, minutes worked) into a dashboard to monitor monthly performance, with a target productivity goal of 95% or higher.

The session also reviewed internal and external auditing processes. Internal audits are conducted through 3M, while external audits are tracked through Excel files. Coders receive regular feedback and participate in ongoing education initiatives, such as colonoscopy education and updates from the Coding Roundtable meetings, to strengthen coding quality and compliance.

We also reviewed metrics posted on the Lens Board, an internal dashboard that tracks coding metrics, bill hold status, educational resources, employee assistance programs, and weekly coding tips. The Lens Board supports transparency and continuous improvement across the outpatient coding team.

Throughout the session, I had the opportunity to observe examples of coding workflows, such as coding from live ED charts, reviewing documentation for completeness, and ensuring that unsigned notes are properly flagged. I learned that attention to detail is critical, especially when coding surgical procedures like laparoscopic cholecystectomy, where the coder must abstract not just the diagnosis but also the procedural details accurately.

Day 7 - March 21, 2025 (Remote) Inpatient Coding

I participated in a session focused on inpatient coding within the University of Maryland Medical System (UMMS). The inpatient team supports multiple facilities, including the University of Maryland Downtown (a trauma hospital), St. Joseph Medical Center, Baltimore Washington Medical Center, Upper Chesapeake Medical Center, and Charles Regional Medical Center. During the session, we reviewed how coding operations differ between specialty hospitals and community-based hospitals. Specialty sites encounter more complex cases such as trauma, organ transplants, coronary artery bypass grafts (CABG), and neonatology, while community sites typically code less complex medical and surgical admissions.

The session was led by Tracy Perzan (Community Inpatient Coding Team Lead) and Angela Baker Langford (Specialty Inpatient Coding Team Lead). They shared their professional backgrounds and offered advice on gaining initial coding experience, highlighting that inpatient coding roles typically require either one year of inpatient experience or two years of outpatient coding experience.

We explored the full inpatient coding workflow, including retrieving patient accounts from Epic and coding them in 3M software. I learned how inpatient coders verify admission status (observation vs. inpatient), analyze discharge summaries, histories and physicals (H&Ps), progress notes, procedure notes, and lab results to determine the correct principal and secondary diagnoses and procedures.

Coders use computer-assisted coding (CAC) tools in 3M, but each suggested code must be reviewed manually. Diagnosis codes, procedures, point of origin, and discharge disposition must all be validated for accuracy. Special attention is given to identifying cases that need queries (such as missing documentation for sepsis, respiratory failure, or pressure ulcers). Queries are initiated in Epic and tracked through 3M, and coders manage documentation deficiencies according to strict guidelines, including seven-day holding periods for unanswered queries.

We also reviewed inpatient-specific metrics. Coders are expected to code 14 inpatient charts per day. Accuracy, appropriate use of the CAC tool, and abstracting point-of-origin and discharge disposition are heavily monitored. Internal and external audits are frequent, and coders are evaluated monthly and annually to ensure compliance with productivity and quality standards.

The session also covered the various coding work queues coders manage daily, including:

· Priority accounts requiring immediate coding for billing

· Accounts waiting for additional documentation

· Query management queues

· Accounts with denials requiring review and appeal documentation

Finally, it was emphasized that strong teamwork, adaptability to frequent workflow interruptions, and maintaining a high standard of accuracy are critical skills for inpatient coders.

Day 7 - March 21, 2025 CDI Clinical Documentation Improvement

One of today’s session centered on Clinical Documentation Improvement (CDI) within the University of Maryland Medical System (UMMS). The session provided a comprehensive overview of how CDI supports coding, billing, compliance, and overall healthcare quality. The instructor, a seasoned professional with experience in both coding and CDI, emphasized the important connection between clinical documentation, coding accuracy, and the financial health of healthcare organizations.

We discussed how CDI specialists review patient records concurrently during the inpatient stay to ensure complete and specific documentation that accurately reflects patient severity and complexity. Proper documentation not only impacts billing and reimbursement but also affects patient care quality metrics, length of stay calculations, and payer coverage decisions. Coders and CDI professionals work collaboratively. Coders identify gaps during coding, and CDI specialists issue queries to providers for clarification or additional specificity.

The instructor also shared his professional journey, highlighting how real-world experiences, networking, and continued education shaped her career path from coding into CDI leadership. He emphasized that strong coding knowledge is essential for any health information management career, especially for those aspiring toward data analysis, compliance, CDI, or management roles.

Key advice included:

· Gaining experience wherever possible, even if starting in coding or HCC (Hierarchical Condition Categories) positions.

· Building strong foundational knowledge in ICD-10-CM coding guidelines and clinical understanding.

· Continuously expanding knowledge through resources such as Coding Clinics, AHIMA publications, and participating in webinars and workshops.

· Developing soft skills such as professional writing, presentation skills, and data interpretation, as these are critical for leadership and career advancement.

· Understanding that AI is increasingly part of coding and CDI processes, but human oversight and clinical judgment remain irreplaceable.

The session also covered career outlooks, certification strategies, and practical tips for interviewing and entering the HIM workforce. We were advised to focus on developing expertise in at least one key area (coding, compliance, data analysis, etc.) to ensure long-term career growth. Additionally, networking, mentorship, and proactive learning were stressed as essential components to successfully transitioning from academic preparation into the professional HIM field.

Day 8 - March 24, 2025 Data Integrity and Chart Correction (Onsite Experience)

The onsite practicum experience focused on gaining general knowledge of the Data Integrity Analyst (DIA) function within the Health Information Management (HIM) Department. This included hands-on observation and participation in chart corrections, patient record merging, and understanding Master Patient Index (MPI) functionality and procedures. Maintaining a clean and accurate MPI is critical to ensuring the quality and continuity of patient care.

During the session, I had the opportunity to observe and assist in real-time chart corrections and record merges, following established hospital protocols. I learned how discrepancies in patient records are identified, verified, and corrected using both manual and system-based tools. I also participated in compiling and developing reports to identify documentation trends and performed audits to assess the presence, timeliness, and quality of documentation in compliance with The Joint Commission (TJC) standards, CMS regulations, hospital policies, and Medical Staff Rules and Regulations.

Conclusion

My clinical practicum at the University of Maryland Medical System (UMMS) Health Information Management (HIM) Department was a transformative and highly educational experience. Throughout eight structured days of both remote and onsite training, I gained a comprehensive understanding of the essential roles and operations within HIM, including regulatory compliance, data integrity, outpatient and inpatient coding, leadership operations, clinical documentation improvement (CDI), and reporting analytics.

Each day built upon the last, starting with an overview of the HIM department’s structure and foundational pillars, then progressing into more specialized functions such as Epic deficiency tracking, best practice workflows, HIM reporting, and real-world coding and CDI collaboration. I observed firsthand how HIM supports not just regulatory compliance and billing accuracy but also enhances patient care and institutional operational excellence.

The onsite experience in Data Integrity further solidified my understanding of maintaining accurate patient records through chart corrections and MPI management. I was able to engage directly in practical HIM activities, audit documentation for compliance with The Joint Commission (TJC) and CMS standards, and witness how critical data governance is to healthcare quality and safety.

This practicum helped me bridge classroom knowledge with real-world application. It strengthened my skills in documentation review, coding workflows, regulatory standards interpretation, report development, and interdepartmental collaboration. I also gained a deeper appreciation for the evolving nature of HIM, especially in areas impacted by new technologies such as AI and the growing importance of strong analytical and leadership skills.

Moving forward, this experience has inspired me to continue building expertise in health information management, particularly focusing on data integrity, coding compliance, and healthcare reporting analytics. The practical knowledge and mentorship I received at UMMS will serve as a strong foundation as I pursue certification and future career advancement in the HIM field.

Student Evaluations Questions

1. What aspects of this experience did you enjoy most? I most enjoyed gaining hands-on exposure to HIM operations, specifically learning about Epic’s Deficiency Tracking Module, inpatient and outpatient coding workflows, CDI processes, and Data Integrity procedures like chart corrections and merges. It was rewarding to see how HIM practices directly impact patient care quality, compliance, and hospital operations.

2. What aspects of this experience did you enjoy least? I enjoyed the entire experience; however, the most challenging part was adjusting to the complexities of inpatient coding workflows, especially balancing productivity expectations with ensuring coding accuracy in high-volume environments. Although challenging, it was an important learning opportunity.

3. In what areas do you feel additional experiences would be helpful? Explain. Additional experience in CDI concurrent record reviews and working more closely with coding queries would be helpful. Observing and drafting provider queries would enhance my understanding of how clinical documentation impacts coding specificity and hospital revenue.

4. Was your theoretical preparation adequate? Yes, my coursework provided a strong foundation, particularly in HIPAA, regulatory compliance, and coding guidelines. However, the practicum gave me a deeper, practical understanding of how these principles apply in real-world healthcare settings.

5. If not, what changes do you think should be made in the lecture/lab/text/library? While my theoretical preparation was strong, it would be beneficial if academic programs incorporated more real-world case studies focused on inpatient workflows, CDI queries, and practical exercises using EHR systems like Epic to better prepare students for the complexity of HIM operations.

6. What did the supervisor(s) do particularly well? The supervisors at UMMS provided excellent guidance, thorough explanations, and valuable real-world insights. They were very open to questions, encouraged hands-on practice, and emphasized the importance of accuracy, attention to detail, and professionalism in the HIM field.

7. What could the supervisor(s) do to improve the effectiveness as a clinical supervisor? No suggestions — the supervisors were extremely effective, supportive, and knowledgeable throughout the practicum experience.

8. Would you recommend this site for future affiliations? Why or why not? Yes, I would highly recommend UMMS HIM for future practicum affiliations. The site offers an exceptional, well-rounded experience across multiple HIM domains including compliance, coding, CDI, and data integrity. The staff are knowledgeable, supportive, and committed to preparing students for real-world success.

Appendix

A. Practicum Schedules and Planning

A1. UMMS Practicum Schedule - Spring 2025

· Title: UMMS PPE Schedule Spring 2025 - BCCC - Raquel

· Content: Detailed clinical rotation schedule for Spring 2025, outlining dates, times, locations (remote and onsite), assigned preceptors, and key HIM activities across different UMMS campuses.

· Document Reference: [UMMS PPE Schedule Spring 2025_BCCC_Raquel.pdf]

A2. Individual Practicum II Schedule

· Title: Lewis Spring Practicum II Schedule

· Content: Personalized tracking document for Raquel Lewis, specifying daily clinical objectives, assigned modules, and rotation areas for Health Information Management exposure during Spring 2025.

· Document Reference: [Lewis Spring Practicum II Schedule.pdf]

B. Departmental Governance and Oversight

B1. HIM UDC Project Charter and Membership 2019

· Title: HIM UDC Project Charter

· Summary:

· Describes the role of the HIM User Defined Committee (UDC) in overseeing HIM applications such as Deficiency Tracking, Patient Identity, Release of Information, Chart Correction, and Coding tools.

· Lists committee objectives including standardization, efficient use of HIM tools, and escalating end-user concerns.

· Provides a roster of key HIM leadership members supporting oversight activities across UMMS.

· Key Reference Points:

· Applications Covered: HIM Document Imaging, Chart Correction, 3M HDM Coding Module, Patient Identity Management.

· Project Completion Date: August 1, 2019.

· Document Reference: [him-udc_project-charter-and-membership_2019.pdf]​

C. Compliance and Regulatory Monitoring

C1. Compliance Overview - 2022

· Title: Compliance Overview - EMPI & Data Integrity

· Summary:

· Outlines the responsibilities of the Document Auditing Specialist (DAS) within the Data Integrity Team.

· Describes the audit focus on TJC and CMS standards, including required documentation elements like H&Ps, Discharge Summaries, Operative Reports, and use of copy/paste in documentation.

· Provides a breakdown of the corrective action plans for non-compliance, including suspension of privileges.

· Lists committees where compliance data is reviewed, such as the Medical Executive Committee (MEC) and Information Management Committee (IMC).

· Document Reference: [Compliance Overview_Rev 2022.pdf]​

D. Visual Documentation and Observations

D1. Practicum Photos

· Titles:

· Organization Chart

· Health Information Management Services: 3 Pillars

· Request for Medical Records

· Medical Record Completion/Suspension Policy

· Evaluation of Clinical Site

· IMG_2570.jpeg

· Description:

· Photographic evidence documenting onsite practicum participation.

· Includes photos related to workflow, organizational chart, policy EMPI correction tracking, report compilation, compliance auditing efforts and student evaluation.