Automation of Health Information UNIT 4 Assignment
Unit 4 Assignment: Analysis of Health Information Management within a Local Clinic and
Clinical Documentation Improvement Programs
Instructions:
Assume you are an Office Manager for a small to medium size physician practice clinic.
Review the Readings from Unit 3 and Unit 4 including the information on Systems
Selection, Implementation, and the Appendix A RFI/RFP reporting format in addition to
the discussion boards and seminar presentations for Units 3 and 4.
Deliverable: Prepare a 3-4-page report that outlines:
The needs of the clinic as it relates to Clinical Documentation Improvement Software
including:
What is Clinical Documentation Improvement?
What, if any, barriers exist to implementing the software?
What is the role of the HIM professional?
The needs of the larger healthcare community/continuum as it relates to Clinical
Documentation Improvement Software.
Research at least three Clinical Documentation Improvement software vendors and review
their systems. At a minimum, include the following information in comparing the vendors
in a table format:
What are the benefits of the system as listed on their web page?
What kind of facility utilizes the vendor’s system?
Is there a coding encoder system component part of the system or available?
Are there any advantages of their system over others (as listed on their web page)?
Any information available in prices, demonstrations, free trials, and implementation.
Could you “see” inside the system on the vendor’s web site?
Conclude your review with a statement of which system you would purchase as a small
office physician practice and why?
In your table or in an additional table, outline the database dictionary terms and
definitions commonly used in the implementation of Clinical Documentation Improvement
software in a Health Information Department.
What items should be included in the reporting database according to the needs of the
clinic as well as the broader health information community/continuum of care?
Are their multiple definitions available for singular terms?
, Name
Institution
Course
Date
Clinical Documentation
Clinical Documentation Improvement are programs that ensure patient’s information and
medical status are accurately stored and represented by translating the data into codes (Brazelton
et al., 2017). The coded data then creates accurate medical reports, reimbursement, treatment
cards, records used to track disease, the discovery of disease trends, and records of public health
status. The programs effectively ensure appropriate initiation of concurrent and retrospective
health record reviews of inpatients. These reviews are conducted remotely or in care units to
correct conflicts, non-specification, and a documentation provider's incompleteness. These
reviews' primary aim is to ensure accurate medical indicators for complete and specific diagnosis
and treatment procedures. CDI communication programs, medical providers, and clinical
physicians share the same clarification method. With CDIS, patients' information and medical
status are accurately documented and coded, proper classifications of disease risks, severity, and
mortality are done. However, even though the many benefits of CDIs acknowledged by health
professionals and practitioners, it comes with its challenges
Unit 4 Assignment: Analysis of Health Information Management within a Local Clinic and
Clinical Documentation Improvement Programs
Instructions:
Assume you are an Office Manager for a small to medium size physician practice clinic.
Review the Readings from Unit 3 and Unit 4 including the information on Systems
Selection, Implementation, and the Appendix A RFI/RFP reporting format in addition to
the discussion boards and seminar presentations for Units 3 and 4.
Deliverable: Prepare a 3-4-page report that outlines:
The needs of the clinic as it relates to Clinical Documentation Improvement Software
including:
What is Clinical Documentation Improvement?
What, if any, barriers exist to implementing the software?
What is the role of the HIM professional?
The needs of the larger healthcare community/continuum as it relates to Clinical
Documentation Improvement Software.
Research at least three Clinical Documentation Improvement software vendors and review
their systems. At a minimum, include the following information in comparing the vendors
in a table format:
What are the benefits of the system as listed on their web page?
What kind of facility utilizes the vendor’s system?
Is there a coding encoder system component part of the system or available?
Are there any advantages of their system over others (as listed on their web page)?
Any information available in prices, demonstrations, free trials, and implementation.
Could you “see” inside the system on the vendor’s web site?
Conclude your review with a statement of which system you would purchase as a small
office physician practice and why?
In your table or in an additional table, outline the database dictionary terms and
definitions commonly used in the implementation of Clinical Documentation Improvement
software in a Health Information Department.
What items should be included in the reporting database according to the needs of the
clinic as well as the broader health information community/continuum of care?
Are their multiple definitions available for singular terms?
, Name
Institution
Course
Date
Clinical Documentation
Clinical Documentation Improvement are programs that ensure patient’s information and
medical status are accurately stored and represented by translating the data into codes (Brazelton
et al., 2017). The coded data then creates accurate medical reports, reimbursement, treatment
cards, records used to track disease, the discovery of disease trends, and records of public health
status. The programs effectively ensure appropriate initiation of concurrent and retrospective
health record reviews of inpatients. These reviews are conducted remotely or in care units to
correct conflicts, non-specification, and a documentation provider's incompleteness. These
reviews' primary aim is to ensure accurate medical indicators for complete and specific diagnosis
and treatment procedures. CDI communication programs, medical providers, and clinical
physicians share the same clarification method. With CDIS, patients' information and medical
status are accurately documented and coded, proper classifications of disease risks, severity, and
mortality are done. However, even though the many benefits of CDIs acknowledged by health
professionals and practitioners, it comes with its challenges
