Learning Objectives
1. Analyze the documentation elements found in the medical record for
their importance to support patient care
2. Assess the importance of a compliance program
3. Discuss recommendations for improvement and training
4. Evaluate technology and workflow and recommend changes
Reading and Resources
Textbook: Healthcare Code Sets, Clinical Terminologies, and Classifications
Systems, Chapters 15 and 18
Chapter 15
This chapter discusses the reasoning for different methods of interchange
between providers and payers. Because there are various forms of
submission medias, there must be different forms of submission capabilities.
One form of submission may work for paper claims, while another may be
required for electronic claims and electronic payments. In this chapter, you
will learn how these formats work together.
Chapter 18
This chapter explains how the various electronic systems use terminology,
classification systems, and value sets to form the electronic records used in
the healthcare industries. The implementation issues that arise from the
electronic technology used today require an efficient way to process the
different forms of health records required in the medical arena. The
information found in this chapter will help you better understand why these
elements are important and how they work together in the daily operations
of the medical facility.
