HCR 210 Entire Course

HCR 210 Entire Course Link 
https://uopcourses.com/category/hcr-210/

HCR/210
PATIENT RECORDS: KEEPING IT REAL
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HCR 210 Entire Course Link
https://uopcourses.com/category/hcr-210/
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HCR 210 Week 1 Patient Self-Determination Act
Resource: Table 1-5 of Essentials of Health Information Management: Principles and Practices
Discuss, in 250 to 300 words, the effect of the Patient Self-Determination Act on health care delivery. Consider how you think records management procedures have had to respond to this piece of legislation.

Submit your assignment to your instructor.
 
 
HCR 210 Week 2 Records Administrators and Technicians
Research job titles, such as medical records clerk, medical records technician, and medical records administrator or others that are involved in medical records maintenance.
Describe, in 250 to 500 words, the various aspects of one of these roles by answering the following questions:

  • What is the position that you are researching?

  • What are the job requirements and duties?

  • Where are the employment opportunities in your community?


 
 
HCR 210 Week 2 U.S. Health Care Settings
Resource: Ch. 3 of Essentials of Health Information Management; Presentation Guide
Review presentation guidelines given in the Presentation Guide located on the student website.
Create a Microsoft® PowerPoint® presentation of at least 9 slides outlining the major functions that distinguish the following U.S. health care settings, with an appropriate introduction and conclusion:

  • Hospital categories

  • Ambulatory care settings

  • Behavioral health care facilities

  • Types of long-term care

  • Managed-care models

  • Home-care service

  • Government health care facilities (federal, state, and local)


Include speaker’s notes on main talking points.
Format any citations and references that you include consistent with APA guidelines.
 
 
HCR 210 Week 3 Record Formats
Resource: Ch. 4 of Essentials of Health Information Management
Summarize, in 250 to 300 words, the differences among source-oriented records, problem-oriented records, and integrated records.
Include how you think the advantages and disadvantages of each record format affect everyday work—remember to think about retrieving records as well as filing them.
 
 
HCR 210 Week 4 Patient Reports
Resources: Appendix C & Ch. 6 of Essentials of Health Information Management
Complete Appendix C.
Submit your completed Appendix C.
Appendix C
Acute Care Patient Reports
Fill in the following table with a general description of each type of patient report, who may have to sign or authenticate it, and the standard time frame that JCAHO or AOA requires for it to be completed or placed in the patient’s record. Four of the reports have been done for you.
 




Name of Report


Brief Description of Contents


Who Signs the Report


Filing Standard




Face Sheet
 


Patient identification, financial data, clinical information (admitting and final diagnoses)
 


Attending physician


30 days following patient discharge




Advanced Directives
 


 


 


 




Informed Consent
 


 


 


 




Patient Property Form
 


 


 


(Not stated in the text, but probably at the time property is taken from the patient)
 




Discharge Summary
 


 


 


 




History and Physical Examination


The patient’s chief complaint, present illness history, past history, family history, social history, current medications, and review of systems


Staff member who directly obtained this information from the patient


Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission
 




Consultation Reports
 


 


 


 




Physician Orders
 


 


 


 




Progress Notes


Notes about ongoing care: changes in the patient, complications, consultations, and treatment


Staff who see the patient sign and attending physician countersigns
 


At the time they occur




Anesthesia Record
 


 


 


 




Operative Report
 


A. History, physical exam, lab and X-ray exams, and preoperative diagnosis
B.  Therapeutic procedures
C.Postoperative  evaluation


Surgeon or attending physician


A.   Prior to surgery
B.    Immediately after surgery
C.    24 hours after surgery
 




Pathology Report
 


 


 


 




Recovery Room Record
 


 


 


 




Ancillary Testing Reports
 


 


 


 




 
 
 
HCR 210 Week 4 Career Self-Reflection I
Complete Appendix D.
Submit your completed Appendix D.
Appendix D
Career Self-Reflection I
 
Maintaining patient files occurs within various types of health care and health care settings. One goal of this course is to help you contemplate choices for your career.
 
From what you’ve learned about medical records and health care settings so far, highlight the choices that best reflect your career interests and explain your reasons:
 
1.     My career interest at this time is more oriented toward:
 

  • Primary care—point of first contact

  • Secondary care—specialist services by referral

  • Tertiary care—unusual disorders


 
because:
 
 
 
2.     If I were to work in a hospital department, I would prefer:
 
· Ambulatory care
· Ancillary services
· Emergency care
· Critical care
· Surgery
 
because:
 
 
 
 
3.     If I were to work in behavioral health care, I would prefer ______________.
 
because:
 
 
 
4.     The medical specialty that interests me most is: ______________.
 
because:
 
5.     The patient population that I am most interested in working with is: ______________. Consider age, language-base, special needs, etc.
 
because:
 
 
 
6.     The career tracks that interest me most are:
 

  • Registry work

  • Coding and reimbursement

  • Transcription

  • Health information management

  • Health services management

  • Staff coordination

  • Risk management

  • Privacy Compliance

  • Other: _________


 
because:
 
 
HCR 210 Week 4 Office Comparison Interviews
Resources: Appendix B

Complete Appendix B and submit to your instructor. Be sure to include discussion on this topic.
Share your experience and thoughts with the class by posting a 150-350 word response discussing the interviews you conducted. Also, attach your completed "Office Comparison Interviews" (Appendix B) document to your post for your classmates (this assignment will be used as a resource in future assignments) to review.
Appendix B
 
Office Comparison Interviews
 
One of the reasons that procedures vary for handling patient records is the volume of patients seen on any given day. By comparing and contrasting record management systems in different sized facilities, you will have information to contribute to several activities in this course.
 
By Week Four you should have completed three interviews, which you may conduct in person or by phone. You need to use the list of questions in the table on the next page to gather information about each of the following:
 
· A small medical facility—an office for one or two doctors
· A medium-sized facility—a clinic where several doctors work in partnership
· A large facility—a hospital or medical center
 
People will be more likely to cooperate if you disclose that the information you want is related to schoolwork, you will not take up much of their time, and none of the information is confidential.
 
Consider introducing yourself with something like the following:
 
Hello, my name is ________ and I need some general information about filing systems for a school assignment. Would it be possible to speak to the person in charge of filing patient records for a few quick questions, or may I call back at another time?
 
If the facility needs proof that you are a student, you must provide your instructor with a name and e-mail address to send a permission notice, and then allow three days for your instructor to send the notice. It is your responsibility to follow up with the prospective facility after your instructor has been notified. When you call back, be sure to ask to speak with the appropriate person, because you cannot expect that the person who answers the phone will know about your request.
 
Once you have permission to proceed, verify that you are talking to a person who is knowledgeable about maintaining patient records there, and ask the questions in the table on the next page.


 




INTERVIEW QUESTION


Small Facility


Medium-sized Facility


Large Facility




1. Approximately how many patient records does your department or facility handle in a typical day?
 


 


 


 




2. Are records in your facility paper, electronic, or both? If paper, are they centralized or decentralized?
 


 


 


 




3. Does your facility use an alphabetic system or a numeric system?
 
If numeric, is it:
· Straight numeric order?
· Middle-digit order?
· Terminal-digit order?
· Other?
 


 


 


 




4. How are reports organized within a patient’s file?
3.      


 


 


 




4.     5a. If paper records: What determines if new information is allowed to remain loose or must be permanently anchored in the record?
 


 


 


 




5.     5b. If electronic records: Where is new information kept until someone has time to enter the information into the electronic record?
6.      


 


 


 




6. If paper records: How many different locations are there in your department that patient files may be found? (For example, are there some temporary holding areas in addition to a permanent area?)
 


 


 


 




7.     7. If paper records: Is there a need to chart the circulation of files from one location to another, so that your staff knows where files are kept?
 
 


 


 


 




8.     What can cause the biggest problem for records management if it isn’t done right?
9.      


 


 


 




10.   What measures in terms of physical storage are taken to ensure the privacy of the medical record?
11.    


 


 


 




10. What measures in terms of personal handling are taken to ensure the privacy of the medical record?
 


 


 


 




12.   Do you have a policy or mechanism to reproduce a lost record?
13.    


 


 


 




12. How do you handle records for patients who no longer visit your facility?
 


 


 


 




13. What changes in procedures do you think would make record management easier or smoother for you? What are your greatest challenges?
 


 


 


 




 
If you do not understand these questions, be sure to ask your instructor for clarification before you begin your interviews. Not every office handles records similarly, and these general questions are designed to get medical employees talking about their procedures. It is possible for the answers you receive to vary substantially.
 
Take notes during your interviews, because you will need this information in upcoming activities. You must complete this Appendix for the assignment in Week Four.
 
 
HCR 210 Week 5 Alphabetic Filing
It can be helpful to remember that nothing comes before something when sequencing filing units. That means a space precedes letters or numbers. Compare the names: Lou Ann and LouAnn. The space after Lou in Lou Ann precedes the A after Lou in LouAnn. Therefore, in a filing system that follows the nothing comes before something rule, Lou Ann comprises two filing units whereas LouAnn comprises one filing unit. Lou Ann precedes LouAnn in the filing sequence—the space comes before the letter.
Resource: Ch. 7 of Essentials of Health Information Management
Use the nothing comes before something rule as you put the following names in alphabetical order, showing the order of filing units (last name, first name, suffix.).

  • Norman Bailey-Jones

  • Norman Bailey Jones

  • Robert D’Angelo

  • Robert D. Angelo

  • Robert DeAngelo

  • Judith delaCroix

  • Judith Dela Croix

  • Franklin M. Haney

  • Franklin Mac Haney, Jr.

  • Franklin MacHaney, Jr.

  • Franklin Mac Haney Sr.


 
 
HCR 210 Week 5 Numeric Filing
Resource: Ch. 7 of Essentials of Health Information Management
Complete Appendix E.
Submit your completed Appendix E.
Appendix E
Numeric Filing
List the following set of numbers within the table below according to:
 
· Straight numeric order
· Middle-digit order
· Terminal-digit order
 
535-11-38
536-01-38
535-01-38
534-10-38
534-10-36
534-01-38
600-11-37
222-10-37
 




Straight Numeric Order


Middle-Digit Order


Terminal-Digit Order




 


 


 




 


 


 




 
 
HCR 210 Week 6 Record Organization
Resources: Ch. 7 of Essentials of Health Information Management and the Week 3 Individual assignment.
Review questions 4 and 5 from your "Office Comparison Interviews" assignment and from at least one of your classmates.
Write a 250-300 word response to the following:

  • What conclusions can you draw about similarities and differences in the organization of patient files and the handling of loose reports within small, medium, and large facilities? If applicable, you may want to review the information about record formats from the Week 3 Individual Assignment.


 
 
HCR 210 Week 6 Record Controls
Review questions 6-12 from your "Office Comparison Interviews" assignment and from at least one of your classmates.
Write a 750- to 1,050- word paper discussing the following:

  • What conclusions can you draw about similarities and differences in circulation, tracking and security measures for records handling and storage within small, medium, and large facilities? Discuss reasons for these differences.

  • Consider how these differences affect other aspects of records management, and postulate consequences of staff not following those procedures properly.


Format your assignment consistent with APA guidelines.
 
 
HCR 210 Week 7 Internet Databases
Resource: Week 7 Electronic Reserve Readings
Discuss in 250 to 300 words the benefits and the concerns of having medical information electronically stored in an Internet database that does not limit the use of patient records to a doctor’s office.
Include your position for or against such a network.
 
 
HCR 210 Week 8 Legal Terms
Resource: Key Terms on the Ch. 9 title page of Essentials of Health Information Management
Select 15 terms from the list of Key Terms from Ch. 9 of the textbook and complete the Legal Terms Individual Assignment.
In your own words, write a brief definition for each of the terms you selected.
Post your definitions as an attachment.
 
 
HCR 210 Week 8 Career Self-Reflection II
Complete Appendix F.
Submit your completed Appendix F.
Appendix F
Career Self-Reflection II
 
Medical regulatory and legal compliance are important areas of health records management. Consider how deeply you might be interested in overseeing these aspects of patient information in your professional work.
 
From what you have learned about compliance issues so far, highlight the choices that best reflect your career interests and explain your reasons:
 
1.     I would enjoy the authority for seeing that documents within patient files are complete, legible, and organized appropriately.
 
· True
· False
 
because:
 
 
 
2.     I would enjoy the authority for ensuring that patient files are filed accurately.  
 
· True
· False
 
because:
 
 
 
3.     I would enjoy the authority for developing procedures to track and circulate medical records effectively.
 
· True
· False
 
because:
 
 
 


4.     I would enjoy the authority for training office employees to follow records management standards.
 
· True
· False
 
because:
 
 
 
5.     I would enjoy the authority for keeping up with changes in filing policies and compliance standards.
 
· True
· False
 
because:
 
 
 
6.     I would enjoy the authority for investigating reports of suspected violations of policies and standards.
 
· True
· False
 
because:
 
 
HCR 210 Week 8 Releasing Protected Health Information
Resource: Ch. 9 of Essentials of Health Information Management
Explain, using 700 to1,050 words, when covered entities may release protected health information only with a patient’s consent and when they may release it without consent, for each category:

  • Government agencies

  • Legal agencies or representatives

  • Research groups


Discuss the principles that permit disclosure of protected health information without a patient’s consent, and state whether or not you feel privacy safeguards are adequate to support those principles.

Include 
at least two outside references.

Format 
your assignment consistent with APA guidelines.
 
 
HCR 210 Week 9 Records Management Presentation
You have been hired as the records manager for Happy Health Medical Clinic, a medium-sized, general practice about to start up business. The practice hopes to have everything computerized in the future, but that is not currently the case. Therefore, basic patient information is stored on computers, but medical information is only found in paper files.
Your facility stores, circulates, and updates patient records internally for six doctors, and traffics them up one floor to an X-ray department—in other words, you loan records, but you do not borrow them. Because the X-ray facility is in partnership with Happy Health, you send actual patient files up to X-ray, not copies, and it is important to get the files back.
Resource: Appendix A, Presentation Guide
Create a 12- to 15-slide Microsoft® PowerPoint® presentation outlining standard records management procedures for the employees who work for Happy Health Medical Clinic. Your presentation should include introduction and conclusion slides, as well as detailed speaker’s notes. The speaker’s notes must describe the bulleted items on the slide and provide rationale for policy decisions. Include one or more complete paragraph of speaker’s notes per slide; cite outside references used, if any, according to APA format.
Include the following information in your presentation:

  • The importance of getting new information into a patient’s record as timely as possible

  • The importance of not duplicating medical records for the same person

  • How one can Be able to know at all times where a record is located as you write practical, how-to procedures to cover the following aspects of records management:


    • Indexes for administering health care information

    • Centralized or decentralized records management

    • Creation of new records—record format

    • Type of filing system:


  • Basic rules of the system

  • Examples to clarify names or numbers that might be confusing in that system


    • Temporary and permanent insertion of loose forms and care reports:


  • Handling clinical data that a doctor needs to see

  • Handling administrative data that a doctor does not need to see


    • Storage for patient files:


  • Short-term (patient returns in 2 to 3 days)

  • Permanent (patient is not due back soon but is currently under care)

  • Archive (patient record has not been used for some time)


    • The physical circulation of records within your facility, and between your facility and X-ray:


  • Routing and tracking records within areas of your department and out to X-ray

  • Storing lab reports that come in when a patient’s file is at X-ray

  • Retention schedule—destruction of records

  • File security

  • Legal and ethical responsibilities


 
 
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