HIT 2100 MOD 2 ASSN

Knowledge Activity: Analyzing for Chart Deficiencies (Associate)

Student instructions

1. If you have questions about this activity, please contact your instructor for assistance.

2. You will review the chart of Virginia Amberg to complete this activity. Your instructor has provided you with a link to the Analyzing for Chart Deficiencies (AS) activity. Click on 2: Launch EHR to review the patient chart and begin this activity.

3. Refer to the patient chart and any suggested resources to complete this activity.

4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS).

The activity

One of the duties of your HIM position is to perform chart analysis for your hospital to ensure that documentation is complete, accurate and timely. The facility has recently purchased Chart Tracking software that includes the ability to flag charts within your EHR for deficiencies based on specific criteria. This new software will be implemented in the coming months. With the improved analysis process this new software will provide, the medical staff would like standardized documentation requirements that must be completed by the healthcare team. Your HIM Director provided you with a list of some of the documentation requirements that she would like the software to analyze. She has also given you a sample patient to perform a manual chart analysis for her review: Virginia Amberg. The Director will present the software, along with your analysis as an example, to the medical staff at their next meeting in preparation for the software rollout.

Review the documentation in Virginia Amberg’s EHR and answer the questions below.

Questions

1. Complete the chart element checklist below, indicating whether the provided requirement is complete, incomplete, deficient or not applicable (N/A) for the specific EHR tab specified in Virginia Amberg’s EHR . Be sure to review the entire EHR. An item should be considered:

· Complete if the item is in the EHR and documented in the required location/tab.

· Incomplete if the item is in the EHR but not documented in the required location. For example, if the patient’s allergies are required to display on the Overview tab, and the allergies are not displayed there, but are documented elsewhere in the chart.

· Deficient if the item is missing from the chart (i.e. the item should be documented in the EHR but you are unable to locate it)

· Not Applicable (N/A) if the specific element is not needed in this patient’s EHR.

If the requirement is not complete, indicate why the item is incomplete, deficient or N/A in the comments section.

Critical thinking questions

2. Assuming the Chart Tracking software will not be intelligent enough to locate information that was not documented in the correct place in the EHR, what format or design changes would you suggest be made to the EHR to ensure information is documented in the correct area for easy analysis?

3. In addition to tracking the requirements listed in the checklist above, what other elements or items would be beneficial to have the Chart Tracking software automatically flag or analyze for the patient’s healthcare team)?

For this assignment, you will complete an activity in EHR Go. Specifically, this week's assignment will include:

· Analyzing Chart Deficiencies

Please follow the instructions below, and reach out to your professor if you have any questions.

1. Click on the  Analyzing Charts for DeficienciesLinks to an external site. and enter your EHR Go credentials to begin. 

1. If you have not yet set up your EHR Go account, you will need to do so before you can begin. Please follow the instructions below.

2. Download the Analyzing Chart Deficiencies activity from the "Overview & Resources" tab of the assignment link.

3. Click on the 2nd tab "Review EHR" to review the chart and begin the assignment.

4. Use the activity sheet to work through the assignment and formulate your answers

5. Complete the attached "M2A1 Analyzing Chart Deficiencies Answer Sheet" and submit as an attachment to this assignment link

Please reach out to your instructor with any questions.

***If you have not yet set up your EHR Go account using the Program Key provided by your instructor, you will need to complete your setup before beginning.

· Please create your EHR Go account by going to:  https://ehrgo.comLinks to an external site. . Select Subscribe in the upper, right corner and enter the following HIT Student Program Key:  S79C42

· Follow the on-screen instructions to create your account then log in. After logging in, you'll be prompted to enter an Activation Code to apply your subscription.

· Your Activation Code has been provided via email by your instructor prior to the first EHR Go activity.

· Setting up your EHR Go account is only completed one time.  You will use the same login information until your subscription expires.

Knowledge Activity: Analyzing for Chart Deficiencies (Associate)

Student instructions

1. If you have questions about this activity, please contact your instructor for assistance.

2. You will review the chart of Virginia Amberg to complete this activity. Your instructor has provided you with a link to the Analyzing for Chart Deficiencies (AS) activity. Click on 2: Launch EHR to review the patient chart and begin this activity.

3. Refer to the patient chart and any suggested resources to complete this activity.

4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS).

The activity

One of the duties of your HIM position is to perform chart analysis for your hospital to ensure that documentation is complete, accurate and timely. The facility has recently purchased Chart Tracking software that includes the ability to flag charts within your EHR for deficiencies based on specific criteria. This new software will be implemented in the coming months. With the improved analysis process this new software will provide, the medical staff would like standardized documentation requirements that must be completed by the healthcare team. Your HIM Director provided you with a list of some of the documentation requirements that she would like the software to analyze. She has also given you a sample patient to perform a manual chart analysis for her review: Virginia Amberg. The Director will present the software, along with your analysis as an example, to the medical staff at their next meeting in preparation for the software rollout.

Review the documentation in Virginia Amberg’s EHR and answer the questions below.

Questions

1. Complete the chart element checklist below, indicating whether the provided requirement is complete, incomplete, deficient or not applicable (N/A) for the specific EHR tab specified in Virginia Amberg’s EHR . Be sure to review the entire EHR. An item should be considered:

· Complete if the item is in the EHR and documented in the required location/tab.

· Incomplete if the item is in the EHR but not documented in the required location. For example, if the patient’s allergies are required to display on the Overview tab, and the allergies are not displayed there, but are documented elsewhere in the chart.

· Deficient if the item is missing from the chart (i.e. the item should be documented in the EHR but you are unable to locate it)

· Not Applicable (N/A) if the specific element is not needed in this patient’s EHR.

If the requirement is not complete, indicate why the item is incomplete, deficient or N/A in the comments section.

Critical thinking questions

2. Assuming the Chart Tracking software will not be intelligent enough to locate information that was not documented in the correct place in the EHR, what format or design changes would you suggest be made to the EHR to ensure information is documented in the correct area for easy analysis?

3. In addition to tracking the requirements listed in the checklist above, what other elements or items would be beneficial to have the Chart Tracking software automatically flag or analyze for the patient’s healthcare team)?