The new director of health information management has been appointed for the Apex Health System. Apex Health System was recently formed when three hospitals began operations under one corporation. Two of the facilities are located inCapital City and the third hospital is located 50 miles away. The two hospitals in Capital City use the same medical staff as they see patients at both facilities.
After a review of the medical staff bylaws, the new HIM director realizes that the health record completion standards in the bylaws are different for each facility. Even though all the hospitals are using the same computerized provider order entry system (CPOE), some facilities require physicians to use the CPOE system and others allow physicians to write orders. The director needs to make a recommendation concerning record completion at the newly formed systems-level Health Information Services committee meeting. The major question is whether record completion guidelines, including sanctions for non-compliant medical staff members, should be the same for all three facilities.
1. Describe the resources that should be reviewed to make a valid recommendation to the committee.
2. If disciplinary action is to occur for noncompliance, how should due process be handled?
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Introduction:
As a medical professor in charge of creating college assignments and answers for medical college students, I understand the importance of health information management in the healthcare system. In this scenario, the new director of Health Information Management at Apex Health System faces a challenge of ensuring consistent record completion guidelines across three hospitals under one corporation. In providing recommendations to the Health Information Services committee meeting, it is essential to consider the resources that should be reviewed and how disciplinary action should be handled for noncompliance.
1. Describe the resources that should be reviewed to make a valid recommendation to the committee.
To make a valid recommendation to the committee, the new HIM director needs to review the medical staff bylaws, hospital policies, federal and state laws related to health information management, and the structure of the three hospitals under the Apex Health System. Medical staff bylaws are crucial in setting the standards and requirements for medical records completion across the organizations. Hospital policies can provide insights into whether physicians are allowed to write orders in some facilities and use a CPOE system in others. Understanding federal and state laws such as HIPAA and HITECH is necessary to ensure compliance in maintaining patient confidentiality and privacy. The hospital structure can also provide insight into how the record completion guidelines and sanctions can be enforced and monitored. It is important to gather data and feedback from medical staff and other relevant stakeholders to make informed recommendations that are evidence-based.
2. If disciplinary action is to occur for noncompliance, how should due process be handled?
Due process should be followed when disciplinary action is required for noncompliance. According to the Joint Commission, the process should involve an investigation of the incident, notification of the parties involved, an opportunity for the accused to respond to the allegations, a hearing, and an appeals process. The accused should have the opportunity to present their case and evidence to a neutral and impartial hearing officer or panel. The hearing process should be conducted in a fair and objective manner, with documentation of the proceedings. After the hearing, the hearing officer or panel should make a recommendation to the appropriate party with the final authority to impose sanctions. It is important to ensure compliance with federal and state laws related to due process to avoid potential legal issues for the organization.
