Learning Experience: Journal Entry, Interview Example
Medical records management entails management, which is responsible for systematic and efficient creation control, maintenance, use, receipt and record disposal including processes to capture and maintain evidence of business activities information and transactions in records (Glance et al, 2011). Needs are there to keep electronic and paper records. This is possible through capturing, automating, storing, and disseminating the records. A record policy should include standards, management, and a policy. The policy should be as broad as possible to ensure that it meets compliance standards, be legally admissible, able to demonstrate compliance and be secure and private.
Records that need management in healthcare include paper records such as facsimiles, regular records, dot matrix and facsimiles. X-ray images including scans, dental images, and electronic records such as email, databases, and various file formats are other records that warrant healthcare management.
Rising costs, which have a relation to electronic information and storage paper, are some of the issues of record management. Lack of paper and electronic records management leads healthcare organizations to incur some risks. Thus, there should be a clear policy concerning records management and healthcare organizations should view records as assets. Paper records have a problem in that they are visible and take up much space (Price, 2011). On the other hand, electronic records are not visible. Healthcare faces problems of employees working without rules, training, standardized organizational structure and procedures. They are to decide, on records, to create, keep, maintain, or destroy as they work in managing emails and computer files. Thus, healthcare management requires the combination of both paper and electronic record management. Since, electronic technology makes work easy, healthcare management in medical service institutions should embrace the use of relevant healthcare systems.
With respect of the administrative roles of persons concerned in the management of medical records, I took a task to find out the roles of Director of Patient Records and the Medical Records Reviewer/Chart Coder. My aim was to know their roles in the healthcare and discover what their jobs entail including the challenges they face as they deliver their duties. I undertook these by administering questionnaires for the two respondents in our healthcare organization. Before I proceeded, with my task, I made sure to obtain consent from my respondents and the public relations department of the healthcare organization.
Director of Patient Records (DPR)
What does the position of Director, Patient Records entail?
“This is a Medical Records Director’s position, which entails compiling, processing, and maintaining hospital and clinic patient records in a way consistent with administrative, medical, ethical, regulatory, and legal requirements in the health care system. As a director of patient records, I am responsible in processing, compiling, maintaining, and reporting patient information for the requirements of health and standards in a way consistent with the numerical coding system of the healthcare industry. I am expected to ensure that patient care runs smoothly while ensuring that the activities stay within the budget of the healthcare organization (Creating an Accurate- and Early-View of Patient Financial Status, 2012). I also work to see into it that I protect medical records security to ensure maintenance of confidentiality.”
What are the challenges you often meet as you deliver your duties?
“Well, I face numerous challenges that include the use of paper and electronic media. While we are striving to go digital, we face challenges of data breach. Data breach in medical services may be informed of identity theft, billing fraud and blackmail (Price, 2011). Data breaches are very serious issues nowadays, and the federal law requires health care providers to report data breaches affecting 500 and over patients to the Department of Health and Human Services. Thus, we should keep our systems up to date and ensure that hackers cannot get access to our systems. We face challenges including large volumes of paper and our systems at times fail. This makes information retrieval difficult. Patients and their families do often complain, and I have to ensure that I address them amicably.”
Medical Records Reviewer/Chart Coder (MRR)
What does your duty entail in day-to-day activities?
The work of MRR is extremely crucial in healthcare organizations. They make sure that the information of patients is kept as accurate as possible. They also keep accurate test results and any data related to the stay of patient’s in the healthcare (Richey, 2000). We then translate the information into a universal code form, used in billing of patients.”
How then do you do the whole work?
In this healthcare organization, we have a team charged with the responsibilities I have mentioned. We as medical coders collect information from the charts of patients. We do this by either collecting information physically from paper records or a computer system. This will then be followed by a review of patient’s chart and checking for inaccurate data, incomplete, ambiguous, or missing. We then assign codes to the information. The coder then verifies the signatures of health officials in the charts of patients. This happens to ensure that the right physicians are credited, or billed for the treatment of patients. Medical coders have to reconcile all data in the patient’s physical chart with the information stored in the computer profiles of the patients (Richey, 2000). Whenever there are any discrepancies, the coder together with a nurse or a physician work to reconcile these. The medical coder assigns codes to the events of the patient’s stay after all the patient information has been double checked and verified. In this case, each code must correspond to a treatment, diagnosis or test. We also perform audits regarding all medical records in the healthcare facility. For this reason, we are referred to as medical auditors. In addition, we carry out the assessment of patient care quality.”
After completing my interviews with my clients, I was able to identify and appreciate the roles of DPR and MRR in medical services. The two positions have clear defined roles to ensure the smooth running of the healthcare organizations (Glance, Metcalf, & Nelson, 2011). In the case of DPR, he or she deals with patient records management. Records are extremely crucial in the running of a healthcare system. DPR interacts a lot with computer hardware and software in programming, writing software, entering data, setting up functions and processing information.
My interview also showed the role of MRR in a healthcare organization. MRR is so crucial in keeping accurate information of the patients. They are concerned with keeping computer systems, maintaining, and updating them as often as is required. Coders also reconcile the physical patient information together with data stored in computer files. Coders also perform auditing for the healthcare organizations.
The Director of Patient Records position is a crucial job in the healthcare. He or she has duties including insuring delivery of high quality and consistent professional service (Price, 2011). He works to meet standards of best practice and sets medical practice agenda. He or she also designates a physician to work in case of absence of the Medical Director. He also develops and implements privileging and credentialing process and policy.
Medical coders or reviewers work in physician offices, hospitals, auditing firms and for nursing homes. They work in auditing medical records for accuracy and completeness by considering various documents in the healthcare organization. Medical reviewers consider each medical record to trace any missing documentation (Glance et al, 2011).
Creating an Accurate- and Early-View of Patient Financial Status. (2012). hfm (Healthcare Financial Management), 66(10), 1.
Glance, D. G., Metcalf, S., & Nelson, C. (2011). Management of Care through Computerised Protocol-Based Care Plans. Communications and Strategies, (83), 59-70.
Price, A. (2011). Primary care quality digest. Quality in Primary Care, 19(6), 405-408.
Richey, B. (2000). Creating a Profitable Partnership. Clinical Data Management, 6(10), 6.
Time is precious
don’t waste it!