Professional Practice Experience (PPE) is a capstone experience of the health information management (HIM) educational process. This workbook has been prepared to assist educators and students with opportunities to experience professional applications within the HIM field when in-person, on-site experiences are not readily available. The exercises in this workbook can also supplement activities or provide a starting point for the development of similar activities when the student is placed on-site in a hosting facility. Activities build on prior experience within the AHIMA VLab™.
AHIMA Professional Practice Experience Workbook
2020
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Contents Preface Acknowledgments Exercises
Exercise 1 Medical Terminology Abstracting: MPI: 1000008 (Darlene Timothy) Exercise 2 Medical Terminology Abstracting: MPI: 1008018 (Marc Dilsby) Exercise 3 Medical Terminology Abstracting: MPI: 151630 (Randall Stover) Exercise 4 Anatomy and Physiology and Disease Processes: MPI: 1001500 (Sandra Fiorentino) Exercise 5 Anatomy and Physiology and Disease Processes: MPI: 1000134 (Larson Anderson) Exercise 6 Anatomy and Physiology and Disease Processes: MPI: 152600 (Sarah Tomlin) Exercise 7 Pharmacology Abstracting: MPI: 138499 (Lucy Lurch) Exercise 8 Pharmacology Abstracting: MPI: ROI3918147 (Cassandra Brinkley) Exercise 9 Pharmacology Abstracting: MPI: 151649 (Alex Harper) Exercise 10 Pharmacology Abstracting: MPI: 151601 (Alicia Paxton) Exercise 11 Linking Diagnoses with Clinical Documentation: MPI: EDCase001 (Adam Cameron) Exercise 12 Linking Diagnoses with Clinical Documentation: MPI: EDCase004 (Lyle Goodrich) Exercise 13 Linking Diagnoses with Clinical Documentation: MPI: EDCase005 (Lonnie Taylor)
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Exercise 14 Linking Diagnoses with Clinical Documentation: MPI: EDCase049 (Marilyn Carter) Exercise 15 Linking Diagnoses with Clinical Documentation: MPI: 152600 (Sarah Tomlin) Exercise 16 Linking Diagnoses with Clinical Documentation: MPI: EDCase020 (Belinda Burton) Exercise 17 Linking Diagnoses with Clinical Documentation: MPI: 1008808 (Christopher Rood) Exercise 18 Linking Diagnoses with Clinical Documentation: MPI: ROI8460786 (Angela Matthews) Exercise 19 Linking Diagnoses with Clinical Documentation: MPI: EDCase016 (Jared Yansey) Exercise 20 Linking Diagnoses with Clinical Documentation: MPI: EDCase011 (Chris Washburn) Exercise 21 Physician Query: MPI: 1000033 (Gerald Cates) IP folder Mon 26-Jan- 2004(5d) Exercise 22 Physician Query: MPI: 151630 (Randall Stover) Exercise 23 Physician Query: MPI: EDCase043 (Amber Allen) Exercise 24 Physician Query: MPI: EDCase006 (Herbert Gillish) Exercise 25 Physician Query: MPI: EDCase013 (Buster Brown) Exercise 26 Medical Terminology Abstracting: ED Female 322228 Authentic Patient Cases Exercise 27 Medical Terminology Abstracting: IP Male 333061 Authentic Patient Cases
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Exercise 28 Medical Terminology Abstracting: IP Female 400233 Authentic Patient Cases Exercise 29 Anatomy & Physiology and Disease Processes: IP Male 394857 Authentic Patient Cases Exercise 30 Anatomy & Physiology & Disease Processes: IP Male 324789 Authentic Patient Cases Exercise 31 Anatomy & Physiology & Disease Processes: ER Male 322223 Authentic Patient Cases Exercise 32 Pharmacology Abstracting: IP Female 398275 Authentic Patient Cases Exercise 33 Pharmacology Abstracting: IP Female 400103 Authentic Patient Cases Exercise 34 Pharmacology Abstracting: IP Female 300282 Authentic Patient Cases Exercise 35 Linking Diagnoses with Clinical Documentation: IP Female 400233 Authentic Patient Cases Exercise 36 Linking Diagnoses with Clinical Documentation: ED Male 322230 Authentic Patient Cases
Exercise 37 Processing Request for PHI: Cattrell, Liberty Exercise 38 Processing Request for PHI: Long Christalline Exercise 39 Processing Request for PHI: Katell, Lori Exercise 40 Processing Request for PHI: Moore, Patricia Exercise 41 Processing Request for PHI: Deer, Cassandra Exercise 42 Processing Request for PHI: Algadumi, Naser Exercise 43 Processing Request for PHI: Sharton, Lucille Exercise 44 Processing Request for PHI: Tomlin, Sarah
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Exercise 45 Processing Request for PHI: Tarkington, Lane Exercise 46 Processing Request for PHI: Badden, Richard Exercise 47 Processing Request for PHI: Tibbs, Carmine Exercise 48 Processing Request for PHI: Case, Fredrick Exercise 49 Processing Request for PHI: Dykstra, Mitchell Exercise 50 Processing Request for PHI: Jefferson, William Exercise 51 Processing Request for PHI: Harper, Alex Exercise 52 Processing Request for PHI: Sanders, Michael Exercise 53 Processing Request for PHI: Bender, Kayla Exercise 54 Processing Request for PHI: Becker, Ronald Exercise 55 Processing Request for PHI: Jarrett, Cindy Exercise 56 Processing Request for PHI: Jameson, Brandy Exercise 57 CIOX E-SmartLog Advanced Search Report Exercise 58 HIPAA Authorization Checklist Exercise 59 Requestor Type Drop Down Menu Exercise 60 Generating Basic Reports Exercise 61 Logging Patient and Continuing Care Exercise 62 ROI Deny Exercise 63 Associate Productivity Exercise 63 Associate Productivity Excel Report Analysis
Appendices
Appendix A: Authorizations and Requests
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Appendix B: Authorization Requirements for the Disclosure of Protected Health Information Appendix C: Answer Sheet for Activities 37–57
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Preface Professional Practice Experience (PPE) is a capstone experience of the health information management (HIM) educational process. This workbook has been prepared to assist educators and students with opportunities to experience professional applications within the HIM field when in-person, on-site experiences are not readily available. The exercises in this workbook can also supplement activities or provide a starting point for the development of similar activities when the student is placed on-site in a hosting facility. Activities build on prior experience within the AHIMA Vlab. The exercises include critical thinking and require the application of skills related to medical terminology, disease processes, pharmacology, clinical documentation, physician queries, release of information, and elements of the master patient index. Students are directed to utilize patient cases and health information sources as well as a variety of health information applications to interpret patient scenarios, analyze data, and present findings, develop reports, and develop education and training materials. Using these activities in coordination with or in the place of PPE will enhance the growth of the HIM student by providing an opportunity to work with health records and related information systems.
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Acknowledgements AHIMA would like to acknowledge Mona M. Burke, MA, RHIA, FAHIMA and Kerry L. Heinecke, MS, RHIA for their content creation contribution to this workbook.
AHIMA would also like to acknowledge Barbara A. Glondys, MA, RHIA, CHPS and Sandra K. Kersten, RHIA, for their contribution to an earlier draft of this workbook.
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Exercises
Exercise 1 Medical Terminology Abstracting: MPI: 1000008 (Darlene Timothy) Instructions: Access the Edco Solcom application. Use the instructions below to complete the case worksheet, identifying medical terms in order to complete each question. 1. Folder: OP THU 30-OCT-2003 Document: Pathology 4/25/2011 Darlene’s Pathology Report revealed that she has a mass on her cervix, giving her a diagnosis of cancer.
What are the medical terms being used in the Pathology Report to describe the mass?
2. Folder: OP THU 30-OCT-2003 Document: Progress Notes 4/25/2011 The physical exam from Darlene’s Progress Note from October 30 th reveals that the patient’s thyroid is not enlarged.
What is the medical term being used in the Progress Note to describe the thyroid?
3. Folder: OP WED 05-NOV-2003 Document: XRay 4/25/2011 In the patient’s XRay Report, it is documented that the “_____” canal has fluid in it.
What medical term describes the location of the fluid in the X-Ray Report?
4. Folder: OP WED 05-NOV-2003 Document: XRay 4/25/2011 The images are obtained using contrast material.
What medical terms describe how the contrast material is administered to the patient?
5. Folder: AS TUE 25-NOV-2003 Document: OP Report 4/25/2011 The OP report describes the position of the patient for the procedure.
What is the medical term(s) are used to describe the patient’s position?
6. Folder: OP MON 08-DEC-2003 Document: OP Report 4/25/2011 Darlene will be going through a short-term treatment designed to target her Stage 1B cancer of the cervix.
What are the medical terms describing the device and its treatment purpose?
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7. Folder: OP MON 08-DEC-2003 Document: OP Report 4/25/2011 In the OP report, the surgeon documented that Darlene does not have infiltration apart from that pertaining to her uterus. What is the medical term being used to describe the area of the uterus that does not have any infiltration of cancer or being of a suspicious nature?
8. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011
In the Progress Note for Darlene, a D & C procedure had been completed with the products of conception being sent over to pathology. The pathology results indicate the tissue samples from the D & C are directly pertaining to products of conception.
What is the medical term being used to describe the state/condition of the endometrial tissue?
9. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011 The physician documented that the only complaint of the patient during this encounter is painful intercourse.
What is the medical term being used to describe the patient’s complaint?
10. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011 In the Assessment portion of the Progress Note, the physician documents that the patient is experiencing a condition pertaining to the cessation of her monthly flow.
What is the medical term(s) being used to describe this condition that the patient is experiencing?
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Exercise 2 Medical Terminology Abstracting: MPI: 1008018 (Marc Dilsby) Example completed medical terminology word breakdown and definition
Patient: Marc Dilsby - Example MR: 1008018 Folder: IP FRI 22-SEP-2000(3d) Document: Outside Records 4/25/2011 (2nd one) Medical Term
Breakdown into Root Word, Prefix & Suffix
photophobia phot/o-, phob, -ia Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report: The patient denies photophobia, preceding aura or recent head or neck trauma. The patient denies any fear of light, preceding aura or recent head or neck trauma. Instructions: Access the Edco Solcom application. In this exercise, you will break each term into its word parts (e.g. root word, prefix, suffix), and then provide a brief explanation of the term. An example is included below in Fig. 2.1, to help you get started. Exercise 2 Patient: Marc Dilsby MR: 1008018
Folder: IP FRI 22-SEP-2000(3d) Document: OP Report 4/25/2011 Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
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Provide a statement from the report that references the term and identify the the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Folder: IP FRI 22-SEP-2000(3d) Document: Progress Notes 4/25/2011 Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Folder: IP FRI 22-SEP-2000(3d) Document: Consultation 4/25/2011 Medical Term
Breakdown into Root Word, Prefix & Suffix
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Provide a statement from the report that references the term and identify the the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
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Exercise 3 Medical Terminology Abstracting: MPI: 151630 (Randall Stover) Instructions:
Access the Edco Solcom application. In this exercise, you will break each term into its word parts (e.g. root word, prefix, suffix), and then provide a brief explanation of the term. An example is included below to help you get started.
Exercise 3
Patient: Randall Stover MR: 151630 Folder: IP THU 27-SEP-2007(4d) Document: History & Physical 4/25/2011 Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement from the report that references the term and identify the meaning of the medical term in the context of the report:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Folder: IP THU 27-SEP-2007(4d) Document: Emergency Room 4/25/2011 (second file) Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Medical Term
Breakdown into Root Word, Prefix & Suffix
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Provide a statement that demonstrates the meaning of the medical term:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Folder: IP THU 27-SEP-2007(4) Document: Nursing Notes 4/25/2011 Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
Medical Term
Breakdown into Root Word, Prefix & Suffix
Provide a statement that demonstrates the meaning of the medical term:
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Exercise 4 Anatomy and Physiology and Disease Processes: MPI: 1001500 (Sandra Fiorentino)
Instructions: Access the Edco Solcom application. Review the patient record to identify and abstract information for each question. Note: For some of the questions, you will be providing word-for-word documentation from the patient’s medical record, looking up information in references (e.g. Internet Search Engine, Journal of AHIMA articles, textbooks, etc.). When a patient has a bump that has formed out of bone at the base of his or her big toe the physician may refer to the condition as “hallux valgus.” What is another name for this condition? a. bunion b. hallux varus c. great toe d. hallux limitus
How many bones are in the human foot? a. 21 b. 16 c. 26 d. 33 How many joints are in the human foot? a. 33 b. 26 c. 21 d. 16 What are the three layers of the skin?
Review the Operative Report. Describe the difference between an “Austin bunionectomy” and a “Reverse Austin tailor’s bunionectomy?”
According to the Operative Report, the patient received anesthesia. What are the areas in which the patient was given local anesthesia? a. 1 st and 3 rd metatarsals left foot b. 2 nd and 4 th metatarsals left foot c. 1 st and 5 th metatarsals right foot d. 1 st and 3 rd metatarsals right foot During the procedure, the surgeon utilized 4-0 vicryl running sutures to close the wound. What layers of skin were the 4-0 vicryl running sutures used to close? The surgeon employed a transverse V-osteotomy through the neck of the metatarsal and the head.
Explain what an osteotomy is.
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In the Operative Report “Findings,” the surgeon documented that the patient has degeneration of articular cartilage.
How would you summarize the significance of the patient’s degeneration of articular cartilage?
Drawing on your knowledge of anatomy and physiology, combined with research on the procedures performed, what is the typical post-op healing like for the type of procedures that the patient had performed?
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Exercise 5 Anatomy and Physiology and Disease Processes: MPI: 1000134 (Larson Anderson) Instructions: Step 1 : Access the Edco Solcom application. Review the patient record to identify and abstract information for each question. Step 2: Create a case presentation: Open a new slide presentation file and format the title slide with the title of this exercise, the course name, your full name, and your instructor’s name. Example of Title Slide Content:
Solcom EDMS A & P/Disease Processes Case 2.5 Introduction to Health Information Technology Johnny Jones Ms. Nora Smith
Step 3: Case Content: Create a 10-15 slide case summary for this patient, including information about the patient’s condition, disease and treatments provided (documented throughout the patient chart in Solcom EDMS), and the patient’s condition at the close of all episodes or documented encounters. Provide detailed information on the identified condition/disease from external references, including the outlook for the condition/disease progression, identifying the structures of the body typically affected, and treatments available for the condition. Presentation Content Criteria (page 2 and following): • Patient name, gender, age (or date of birth) & diagnosis (main reason for treatment) Ex: Jerry Toll, Male, Age 46 Lung Cancer • Synopsis (summary) of patient encounters and treatment provided
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• Information about the condition and/or disease (from research) • What is the outlook for the patient? (based on your research)
• Identify the structures of the body typically affected by the condition (from research) • Provide information about the types of treatment(s) available to patients with this condition (from research) Step 4: Last slide: Create an APA-formatted bibliography, citing the external resources you used to research the condition and/or treatments.
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Exercise.6 Anatomy and Physiology and Disease Processes: MPI: 152600 (Sarah Tomlin) Instructions: Step 1: Access the Edco Solcom application. Review the patient record to identify and abstract information for each question. Step 2: Create a case presentation: Open a new slide presentation file and format the title slide with the title of this exercise, the course name, your full name, and your instructor’s name. Example of Title Slide Content:
Solcom EDMS A & P/Disease Processes Case 2.5 Introduction to Health Information Technology Johnny Jones Ms. Nora Smith
Step 3: Case Content: Create a 10-15 slide case summary for this patient, including information about the patient’s condition, disease and treatments provided (documented throughout the patient chart in Solcom EDMS), and the patient’s condition at the close of all episodes or documented encounters. Provide detailed information on the identified condition/disease from external references, including the outlook for the condition/disease progression, identifying the structures of the body typically affected, and treatments available for the condition. Presentation Content Criteria (page 2 and following): • Patient name, gender, age (or date of birth) & diagnosis (main reason for treatment) Ex: Jerry Toll, Male, Age 46 Lung Cancer • Synopsis (summary) of patient encounters and treatment provided
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• Information about the condition and/or disease (from research) • What is the outlook for the patient? (based on your research)
• Identify the structures of the body typically affected by the condition (from research) • Provide information about the types of treatment(s) available to patients with this condition (from research) Step 4: Last slide: Create an APA-formatted bibliography, citing the external resources you used to research the condition and/or treatments. Submit the presentation to your instructor.
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Exercise 7 Pharmacology Abstracting: MPI: 138499 (Lucy Lurch) Part A Instructions: Access the Edco Solcom application. • Review the patient record to locate documentation that would include medications ordered/given to the patient (e.g. Medication Administration Record (MAR), physician orders, anesthesia records, nursing notes, etc.) • Identify eight drugs total (any route) given to the patient during the hospitalization; the first one has been completed for you. • Note: For some of the questions, you may need to look up information in references (e.g. Internet Search Engine, Journal of AHIMA articles, textbooks, etc.).Fill in the brand name, generic name, dosage given to patient, and route(s) of administration used. BRAND NAME GENERIC NAME DOSAGE GIVEN TO PATIENT ROUTE(S) OF ADMIN Synthroid Levothyroxine 0.15 mg tablet Oral Part B Instructions: Choose 3 drugs (your instructor may specify which ones) from the list you compiled in Part A (your instructor may specify which ones): • Identify the system(s) of the body that the medication impacts. • Explain why you feel the medication was given or prescribed to the patient. Drug 1: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 2: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 3 (Answers will vary). Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because:
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Exercise 8 Pharmacology Abstracting: MPI: ROI3918147 (Cassandra Brinkley) Part A Instructions: Access the Edco Solcom application. • Review the patient record to locate documentation that would include medications ordered/given to the patient (e.g. Medication Administration Record (MAR), physician orders, anesthesia records, nursing notes, etc.) • Identify eight drugs total (any route) given to the patient during the hospitalization; the first one has been completed for you. • Note: For some of the questions, you may need to look up information in references (e.g. Internet Search Engine, Journal of AHIMA articles, textbooks, etc.).Fill in the brand name, generic name, dosage given to patient, and route(s) of administration used. BRAND NAME GENERIC NAME DOSAGE GIVEN TO PATIENT ROUTE(S) OF ADMIN Celebrex Celecoxib 200 mg Oral Part B Instructions: Choose 3 drugs (your instructor may specify which ones) from the list you compiled in Part A (your instructor may specify which ones): • Identify the system(s) of the body that the medication impacts. • Explain why you feel the medication was given or prescribed to the patient. Drug 1: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 2: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 3: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because:
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Exercise 9 Pharmacology Abstracting: MPI: 151649 (Alex Harper) Part A Instructions: Access the Edco Solcom application. • Review the patient record to locate documentation that would include medications ordered/given to the patient (e.g. Medication Administration Record (MAR), physician orders, anesthesia records, nursing notes, etc.) • Identify six drugs total (any route) given to the patient during the hospitalization; the first one has been completed for you. • Note: For some of the questions, you may need to look up information in references (e.g. Internet Search Engine, Journal of AHIMA articles, textbooks, etc.).Fill in the brand name, generic name, dosage given to patient, and route(s) of administration used. BRAND NAME GENERIC NAME DOSAGE GIVEN TO PATIENT ROUTE(S) OF ADMIN Avonex Part B Instructions: Choose 3 drugs (your instructor may specify which ones) from the list you compiled in Part A (your instructor may specify which ones): • Identify the system(s) of the body that the medication impacts. • Explain why you feel the medication was given or prescribed to the patient. Drug 1 Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 2: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 3: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because:
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Exercise 10 Pharmacology Abstracting: MPI: 151601 (Alicia Paxton) Part A Instructions: Access the Edco Solcom application. • Review the patient record to locate documentation that would include medications ordered/given to the patient (e.g. Medication Administration Record (MAR), physician orders, anesthesia records, nursing notes, etc.) • Identify the five drugs total (any route) given to the patient during the hospitalization; the first one has been completed for you. • Note: For some of the questions, you may need to look up information in references (e.g. Internet Search Engine, Journal of AHIMA articles, textbooks, etc.).Fill in the brand name, generic name, dosage given to patient, and route(s) of administration used. BRAND NAME GENERIC NAME DOSAGE GIVEN TO PATIENT ROUTE(S) OF ADMIN Tylenol Acetaminophen 15 gram Oral Part B Instructions: Choose 3 drugs (your instructor may specify which ones) from the list you compiled in Part A (your instructor may specify which ones): • Identify the system(s) of the body that the medication impacts. • Explain why you feel the medication was given or prescribed to the patient. Drug 1: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 2: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because: Drug 3: Generic Name: Body system(s) impacted: I feel this medication was prescribed to the patient because:
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Exercise 11 Linking Diagnoses with Clinical Documentation: MPI: EDCase001 (Adam Cameron) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist.
11
Exercise #:
Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6.
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Surgery/Procedure: Surgeon: Was Anesthesiologist Present?
Y/ N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Review Physician’s Discharge Instructions. Are there any instructions not linked to diagnoses?
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Exercise 12 Linking Diagnoses with Clinical Documentation: MPI: EDCase004 (Lyle Goodrich) Instructions: Accessthe Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 12 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/ N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: What facts (documentation) from the Objective (O) section of the physician’s note support the care that is being provided? What information provided in the Plan (P) supports the care that is being provided for one or more diagnoses for this patient encounter?
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Exercise 13 Linking Diagnoses with Clinical Documentation: MPI: EDCase005 (Lonnie Taylor) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 13 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Review the physician’s exam. Which components support the diagnosis ((e.g. General, Head, EENT, etc.)? Review the XRay report. Which statements support the patient’s diagnosis?
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Exercise 14 Linking Diagnoses with Clinical Documentation: MPI: EDCase049 (Marilyn Carter) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 14 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
Y/N (include procedure, if yes)
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Using the Radiology Report and other documentation in the chart, describe the fracture type.
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Exercise 15 Linking Diagnoses with Clinical Documentation: MPI: 152600 (Sarah Tomlin) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 15 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Locate the H&P and provide a brief synopsis of the patient’s condition: Compare the Admitting and Final Diagnosis. What evidence supports the final diagnosis?
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Exercise 16 Linking Diagnoses with Clinical Documentation: MPI: EDCase020 (Belinda Burton) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 16 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Include statements from the documentation that describe the patient’s “abrasions” and the corresponding treatment: Include statements from the documentation that describe the patient’s “lacerations” and the corresponding treatment:
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Exercise 17 Linking Diagnoses with Clinical Documentation: MPI: 1008808 (Christopher Rood) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 17 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Not available Was Anesthesiologist Present? Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Not available Discharge Instructions: Discharge Status: What treatment was provided to the patient prior to the surgery (review surgeon’s notes, outside records). Why was surgery recommended for this patient?
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Exercise 18 Linking Diagnoses with Clinical Documentation: MPI: ROI8460786 (Angela Matthews) Instructions: Accessthe Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 18 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: *Using postoperative diagnosis (no DS provided) and Face Sheet for Reference 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6.
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Surgery/Procedure: Surgeon: Not Available Was Anesthesiologist Present? Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Review the Consult. Who was the referring provider? N/A What is the consultant’s recommendation for treatment? Was a copy provided to the referring provider?
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Exercise 19 Linking Diagnoses with Clinical Documentation: MPI: EDCase016 (Jared Yansey) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 19 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Review the Subjective (S) section of the physician’s documentation. Describe the location and wound of the injury. Why would the physician order Keflex (a strong antibiotic) for this patient?
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Exercise 20 Linking Diagnoses with Clinical Documentation: MPI: EDCase011 (Chris Washburn) Instructions: Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment. For injuries, document the place and nature of the injury. For surgical cases, review for surgical consent, and participation of anesthesiologist. Exercise #: 20 Patient Name: MPI: Patient Type: Chief Complaint or Reason for Admission:
Injury? If yes, describe type of injury, place of occurrence, and whether this is initial or follow-up treatment:
Diagnosis: 1. 2. 3. 4. 5. 6.
Link to Dx #
Physician Orders:
Status:
1. 2. 3. 4. 5. 6. Surgery/Procedure:
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Surgeon: Was Anesthesiologist Present?
Y/N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: Design a questionnaire that could be used as a guide for new physicians to assist with documenting treatment of wounds/injuries. Note: Minimum number of questions for the questionnaire is five.
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Exercise 21 Physician Query: MPI: 1000033 (Gerald Cates) IP folder Mon 26-Jan-2004(5d) Instructions: Accessthe Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment; analyze the record for legibility and complete documentation; determine if more information from physician is required for complete coding, and if yes, develop a compliant query. Writing a Compliant Query A proper query process ensures providers add appropriate documentation to the health record in support of accurate code assignment. Personnel performing the query function should maintain a compliant query process. Although verbal queries may be prevalent in the physician practice setting due to the close working relationship, it is important to follow guidance requiring their recording. When writing a query in the physician practice setting, the CDI professional must adhere to the following guidelines: • Do not lead the provider to a certain diagnosis • Include appropriate clinical indicators to support the query • Format the query as open-ended (preferred), multiple choice, or “yes/no” (or “rule in/rule out”) Refer to AHIMA’s January 2016 Practice Brief “Guidelines for Achieving a Compliant Query Practice (2016 Update),” available online in AHIMA’s HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples.
References:
Guidelines for Achieving a Compliant Query Practice (2019 update) found at the AHIMA Body of Knowledge at http://bok.ahima.org/doc?oid=302673#.Xnu3uKhKiUl Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M. "Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities" Journal of AHIMA 88, no.5 (May 2017): 54-58. Exercise #: 21 Patient Name: MPI: Patient Type: List the discharge diagnoses from the record and identify documents from the record that support the diagnosis: Diagnosis: Supporting Documentation:
1. 2. 3.
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4. 5. 6.
Treatment Provided:
Link to Dx #
1. 2. 3. 4. 5. 6. Assess accuracy/completeness of documentation: Are all documents legible?
(Y/N, if no, list problems)
Is additional documentation needed to support diagnoses (as documented by physician, or possible diagnoses identified by coder)? (Y/N) Propose wording for compliant physician query, if needed.
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Exercise 22 Physician Query: MPI: 151630 (Randall Stover) Instructions:
Accessthe Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment; analyze the record for legibility and complete documentation; determine if more information from physician is required for complete coding, and if yes, develop a compliant query. Writing a Compliant Query A proper query process ensures providers add appropriate documentation to the health record in support of accurate code assignment. Personnel performing the query function should maintain a compliant query process. Although verbal queries may be prevalent in the physician practice setting due to the close working relationship, it is important to follow guidance requiring their recording. When writing a query in the physician practice setting, the CDI professional must adhere to the following guidelines: • Do not lead the provider to a certain diagnosis • Include appropriate clinical indicators to support the query • Format the query as open-ended (preferred), multiple choice, or “yes/no” (or “rule in/rule out”) Refer to AHIMA’s January 2016 Practice Brief “Guidelines for Achieving a Compliant Query Practice (2016 Update),” available online in AHIMA’s HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples.
References: AHIMA Inpatient Query Toolkit
Guidelines for Achieving a Compliant Query Practice (2019 update) found at the AHIMA Body of Knowledge at http://bok.ahima.org/doc?oid=302673#.Xnu3uKhKiUl Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M. "Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities" Journal of AHIMA 88, no.5 (May 2017): 54-58. Exercise #: 22 Patient Name: MPI: Patient Type: List the discharge diagnoses from the record and identify documents from the record that support the diagnosis: Diagnosis: Supporting Documentation:
1. 2. 3.
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4. 5. 6.
Treatment Provided:
Link to Dx #
1. 2. 3. 4. 5. 6. Assess accuracy/completeness of documentation: Are all documents legible?
(Y/N, if no, list problems)
Is additional documentation needed to support diagnoses (as documented by physician, or possible diagnoses identified by coder)? (Y/N) Propose wording for compliant physician query, if needed.
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Exercise 23 Physician Query: MPI: EDCase043 (Amber Allen ) Instructions:
Access the Edco Solcom application. In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment; analyze the record for legibility and complete documentation; determine if more information from physician is required for complete coding, and if yes, develop a compliant query. Writing a Compliant Query A proper query process ensures providers add appropriate documentation to the health record in support of accurate code assignment. Personnel performing the query function should maintain a compliant query process. Although verbal queries may be prevalent in the physician practice setting due to the close working relationship, it is important to follow guidance requiring their recording. When writing a query in the physician practice setting, the CDI professional must adhere to the following guidelines: • Do not lead the provider to a certain diagnosis • Include appropriate clinical indicators to support the query • Format the query as open-ended (preferred), multiple choice, or “yes/no” (or “rule in/rule out”) Refer to AHIMA’s January 2016 Practice Brief “Guidelines for Achieving a Compliant Query Practice (2016 Update),” available online in AHIMA’s HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples.
References
AHIMA Inpatient Query Toolkit Guidelines for Achieving a Compliant Query Practice (2019 update) found at the AHIMA Body of Knowledge at http://bok.ahima.org/doc?oid=302673#.Xnu3uKhKiUl Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M. "Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities" Journal of AHIMA 88, no.5 (May 2017): 54-58. Exercise #: 23 Patient Name: MPI: Patient Type: List the discharge diagnoses from the record and identify documents from the record that support the diagnosis: Diagnosis: Supporting Documentation:
1. 2. 3.
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