Healthcare Information Systems

Question 1

Many hospitals have systems in place and are now or will in the future face the task of determining which data in the previous system should be migrated or mapped to the new system. Look at this topic from both the health information management (HIM) and information systems perspective. Select one or two systems, such as registration; admission, discharge, and transfer (ADT); billing; chart tracking, or release of information, and identify which data elements would need to be brought forward to a new system and why. Identify which data elements have long-term value for patient care and which data elements must be preserved and accessible but may not be actively used for patient care.  

Question 2

Construct a hierarchy chart and data flow diagram for the physician chart completion process listed here. 

Physician Completion Process (Determine whether facility is using a paper record system or an electronic system. Adapt the process to fit the health record system.)

1. Physician notified of incomplete records.
2. Physician requests incomplete records.
3. Access documentation management application to identify records.
4. Pull or identify incomplete records.
5. Give records to physician or electronically post "to do" list.
6. Physician completes records.
7. Physician returns records to HIM staff (paper system).
8. HIM staff reviews records to determine whether physician completed all deficiencies.
9. HIM staff removes deficiencies cited for the physician in the documentation management system or review system report for physician.
10. HIM creates monthly or periodic reports-for individual physician, for physician's department chair, and for appropriate committees.

Ongoing process:

1. If deficiencies still exist for same physician after some portion of work is done to complete records, then HIM staff updates status in documentation management system.
2. Notification to physician.

 Note: All references must be in APA format