HEALTH INFORMATION MANAGEMENT

RHEA/191160036/BHIM
UNIT- 5
1. Describe the roles of clinical and administrative staff in
interdisciplinary health care documentation.
Clinical documentation specialists work for hospitals or
medical service providers to monitor the quality of medical
records and documents. This includes making sure records
contain a sufficient amount of information about diagnoses,
treatments, and follow-up required. Clinical documentation
specialists deal primarily with doctors, nurses, and other
health professionals to clarify issues and add missing
information to ensure policies and regulations are met. The
hours for this job vary depending on the organization, though
there may often be long shifts and some larger facilities may
require a clinical documentation specialist to be on duty at all
times, so the position is shared. People well suited to
becoming clinical documentation specialists are strong
communicators who are organized and detail oriented.

Clinical Documentation Specialist Duties and Responsibilities

Based on job listings we analysed, clinical documentation

specialists’ duties typically involve:

Collecting Patient Information

Clinical documentation specialists collect information from
medical teams about patients’ diagnoses and enter it into a
computer database for security. They conduct research and
perform administrative duties as well.

Assess Medical Documents for Accuracy

Clinical documentation specialists assess all medical

documents for accuracy and ensure that records are
systematically organized so that they can be easily located at
a later date.

Check that Clinical Documents Comply with Laws

Clinical documentation specialists check that all medical

documents comply with federal laws in terms of how they
are composed and stored. They are responsible for assessing
systems and recommending strategies for improving the
record keeping process to provide better service to staff and
patients alike.

Prepare Written Reports

Clinical documentation specialists work with staff to interpret

reports to identify health-related patterns and assist in
addressing health problems in patients, as well as preparing
written reports for public health officials who evaluate the
healthcare facilities.

Meet with Clinical Staff to Explain Reports

 Clinical documentation specialists meet with clinical staff to
explain reports. This involves applying their knowledge of
medical terminology and procedures to evaluate clinical
documents and address any issues in the reports.

Clinical Documentation Specialist Skills and Qualifications

Typically, employers require an associate’s degree and

several years’ experience in a similar role, as well as the
following abilities:

 Detail oriented – clinical documentation specialists work

with medical documents and clinical assessments to identify
problems or trends, so having good attention to detail is
important to ensure that nothing of importance is missed or
ignored
 Interpersonal skills – excellent interpersonal and
communication skills are necessary to remain polite,
courteous, and professional while dealing with a variety of
different people in different roles
 Critical thinking skills – clinical documentation
specialists analyse medical information to provide better
service to patients and to apply medical knowledge to
evaluate clinical documents, requiring effective problem-
solving skills
 Confidentiality – clinical documentation specialists work
with confidential information on a daily basis, so they should
have knowledge of privacy laws and maintain a level of
confidentiality to protect patients.
 Training – clinical documentation specialists train
information specialists on the proper methods of
documentation and maintaining medical records properly,
and teach medical coders standard procedures to follow
when composing medical documents
 

Clinical Documentation Specialist Education and

Training

The minimum requirement to become a clinical

documentation specialist is an associate’s degree in health
information technology. These programs often include
computer training, how to access medical record information
systems, and medical coding and terminology. More
advanced qualifications include a bachelor’s degree in health
services, public health, or care administration. Some
employers may require work experience in addition to a
formal qualification. Graduates from health information
technology associate’s programs can also earn AHIMA’s
Registered Health Information Technician (RHIT) credential as
well. Clinical documentation specialists are expected to
continue their education to stay up to date with the latest
laws governing patient information.

Clinical Documentation Specialist Salary and Outlook

The median annual salary for clinical documentation

specialists is nearly $69,000. Clinical documentation
specialists in the 10th percentile earn around $48,000
annually, while the highest paid earn close to $93,000 a year.
Some companies have bonus structures which can offer up to
$6,000 in additional income.

Location and level of experience impact the pay level; many

employers offer dental plans and medical insurance as part of
their benefits package. The Bureau of Labor Statistics predicts
the growth rate for this sector to grow by 13 percent through
2026.

Helpful Resources

We’ve collected some of the best resources to help you

develop a career as a clinical documentation specialist:

The Clinical Documentation Improvement Specialist’s Guide

to ICD-10 – This revised version of a trusted reference guide
explains the ICD-10 documentation and clinical indicators
those working as a clinical documentation specialist may
come across. It covers the latest tested tips and tools, as well
as strategies to implement successful programs.

Clinical Documentation Improvement Specialists

Handbook – This book aims to be an inclusive reference for
clinical documentation specialist professionals. It covers the
fundamentals of coding, querying physicians, and helps to
develop strong interdepartmental communication.
ACDIS – The Association for Clinical Documentation
Improvement Specialists site is packed with useful
information that will help anyone beginning a career in this
field, or those who want to stay up to date with the latest
developments. The resource library, in particular, is a handy
collection of whitepapers, webcasts, and more.

AHIMA Journal – The American Health Information

Management Association’s blog highlights best practices in
health information management and the emerging issues in
the field, such as privacy, security, and accuracy of patient
information.

2. Describe the importance of standardized

documentation.

Literature within the medical field increasingly reports

the need for standardized
Patient records, with a strong argument that the
absence of a centralized data
Recording system seriously limits the understanding of
treatment effectiveness
(CIPP, 1999; Lennox, Taylor, Rey-Conde, Bain, Boyle and
Purdie, 2004; Liber,
2004; Taylor, 2003). Star field and Schiff (1972) indicated
that, as a historical
Problem, the lack of a standardized patient form is the
initial cause, thus
Explaining why certain data are missing in the patient’s
charts. In an evaluation
Of paediatric care, Stewart, Roth, and Kirk bride (1995)
conclude that generating
An official report from the patient’s medical charts
would have been impossible
Without their employing two investigators who utilized
a standard instrument to
Perform record reviews. They also justified the
importance of utilizing standardized
Instruments to record data so that the reviewers could
accurately and efficiently
Complete the evaluation of treatment effectiveness.
Likewise, Taylor (2003) states,
“Important and pertinent information may be difficult to
find because it has been
Recorded in an inappropriate place” (p. 752).
Unintentional errors, due to a lack
Of standardized recording procedures, pose the
problem of practitioners’ inability
To record or locate necessary information.
Standardized recording procedures are often portrayed
as useful tools in the
Supervisory and decision-making processes. Linking the
public child welfare
System to its interdisciplinary connection with health
care providers, McDevitt
(1994) states that a “simple, comprehensive” format can
ensure that caseworkers
View the standardized tool as part of their assessment
skills rather than additional
Paperwork (p. 47). This perception helps professionals
from various disciplines
Respect the use of a standardized instrument as an aid
to comprehensive
Assessment in order to achieve clinical judgment and
cultural relevancy (Wald
And Woolverton, 1990). Wren, Rod Ewald, Lomb, and
Solves (1993) in a study
Of patient forms found that most professionals favored
the use of structured

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138 S. Kulbeth & M. Cheung

forms over the free-text record keeping process. The
subjectivity of assessments
is removed through standardized forms and leads to
improved resource use and
enhanced clinical practice, better communication, and
provides documentation
for quality assurance review and clinical data
dissemination (Brissett-Chapman,
1997). However, Reilly (2006) warns professionals about
power struggles as they
may push areas that reflect their particular expertise,
leading to creating lengthy,
duplicated and complex documents.
A mental health area that is frequently connected with
the health care system is
domestic violence. Spath (2003) states that standardized
risk assessment measures
are imperative for recording risk factors and indicators
of domestic violence.
Without standardized risk assessment forms there may
not be an appropriate
Place to document the information. A standardized
instrument provides a method
Of assessment for the presence of domestic violence
indicators and the degree to
Which they predict an outcome of domestic violence in
the future. The absence
Of such a tool may lead to many of the risk factors being
overlooked or regarded
As having little impact on the injured patient.
Nevertheless, the time constraints
Placed on workers to document and close cases are
noted as a hindrance to
Exploring the presence of domestic violence within a
family when the chief
Focus of record keeping is placed on evidence for
allegations, not service delivery
(Spathe, 2003). These views emphasize the point that
standardization is a means
To ensure that relevant information will not be
unintentionally overlooked. This
 Discussion further attests to the need for record
keeping, not only for health care
Or mental health assessment, but also for risk
assessment, treatment planning,
As well as for documenting evidence.
Various publications have examined the need for
standardized recording
With reference to treatment outcome research,
continuity of care, and selection
Of appropriate intervention and prevention techniques
(CIPP, 1999; Lorence,
Spink, and Jameson, 2002; Maradieque, 1989; Stewart
et al., 1995; Wenzel,
2002). in this time of ever increasing demand for
treatment outcome measures
In the social service profession, efforts have been made
to justify agency-based
Decisions. Wenzel (2002) urges the use of an interactive,
all-encompassing,
Interdisciplinary, electronic assessment tool to reduce
the number of cumbersome,
But necessary procedures. This tool aids in the
development of an efficient

3. What are the implications of the role of social workers

in interdisciplinary health care documentation?
Certainly, there are gaps within the record keeping
processes in the health care industry, especially among
the professionals on interdisciplinary teams. These
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Record Keeping in Interdisciplinary Practices 141 gaps
significantly impede researchers’ and practitioners’
ability to accurately and empirically assess treatment
measures and patient outcomes. At the same time, such
disparities may also hinder the interdisciplinary
approach and interrupt the continuum of care. Though
limited in the number of studies cited, the findings of
this study identify three major issues: 1) records are
kept for different purposes, which may affect the
effectiveness of interdisciplinary practices; 2) different
disciplines have different rules regarding confidentiality,
which implies a need for further examination; and 3)
with technology being advanced quickly, patient access
to records is silently imposing another area of concern
on all professionals. As these mounting concerns
continue to rise, social workers are called upon to
participate fully and coordinate with many
interdisciplinary teams. Within the medical setting, the
literature suggests that some preliminary requirements
for an integrated record keeping system in an
interdisciplinary environment include self-auditing,
standardization, and participation (Dickie and Bass,
1980; Thompson et al., 2002). At the same time, the
social work literature advises that social workers should
assume a leadership role by promoting these strategies
and examining the relationships between service quality
and record quality (Rodriguez, 1988). However, such
leadership role assumption by social workers in
interdisciplinary record keeping has not yet been
documented. This study raises questions about who is
engaged in the information systems design and the level
and type of involvement social workers should have in
the conceptualization of such systems. Concrete
examples of how social workers could join the team of
“designing,” “owning” and/or “using” these information
systems is not provided within the literature. Without
social workers’ input, gaps will continue to emerge
when practitioners refuse to embrace current
information systems and do not see their relevancy to
practice. Another role for social workers is to determine
the best standardized practices of data collection to be
used for evaluation purposes. Among professionals, it is
common knowledge that the comprehensiveness of
records is vital for proper evaluation of diagnosis, client
progress, satisfaction, and treatment effectiveness
(Jungmann, Goebel and Remschmidt, 1978; Kooyman
and Rae, 2003; Lennox et al., 2004). The hindrances to
record keeping practices outlined in this analysis define
the need for establishing an evaluative component in
record keeping. Measures are necessary to ensure both
the quantity and quality of information obtained by
clinicians. Such outcome measures can only be obtained
through accurate dissemination of information as
documented in the patients’ records. It is necessary for
researchers to obtain record data to empirically study
treatment techniques, to relay information relevant to
the allocation of resources, and to determine the need
 for treatment design modification. However, the various
methods utilized Social Work_V40.indb 141 3/15/2007
8:32:10 AM 142 S. Kulbeth & M. Cheung for gathering
information and evaluating clients, even within the
same system, are not always consistent. Without
congruence among practice techniques and measures,
treatment cannot be accurately measured.

UNIT-6
1. Describe the Role of HIM Professional in Research.

To provide specific information on how HIM

professionals can involve themselves in research, this
Article focuses on the roles of HIM practitioners and
researchers in the integration of IT in a network of
State wide healthcare providers. The success of this
project will depend on the integration of HIM
Practitioner skills and knowledge in areas of research
design, information systems, and clinical setting
Applications. Both clinical expertise and knowledge of
basic research methods on the part of the HIM
Professional are essential in being able to ask
appropriate questions and access the necessary data to
Support the research project.
This research project centres on the impact of
implementing technology to improve the flow of
Data, transformation of data to information, and
practical application of this knowledge on improving
Patient care. The study will incorporate the following
knowledge and skills embodied by HIM faculty:

1. The creation of a database using UMMC’s laboratory,

administrative, and billing information to
Capture study outcomes: The HIM professional is
uniquely qualified in the design and
Construction of such databases, which integrate
multiple data sets.
2. Working closely with the institution’s IT department
to develop a Web-based vehicle for a
reporting structure for rural hospitals: HIM professionals
possess knowledge of human disease
processes and may serve in a consultative role with IT
personnel to coordinate implementation
and design educational tools for training healthcare
providers.
3. Expansion of IT into rural areas in order to link rural
hospitals with UMMC to both improve
understanding of hospitals in the state and provide
consultants to rural facilities: The HIM
professional is uniquely equipped to fill the consultative
role, linking rural facilities to UMMC
through IT.
 4. Development of educational models to demonstrate
concepts of continuous quality improvement
And the utility of outcome measures as a means to
measure performance improvement: HIM
Professionals possess expertise in performance
improvement and continuous monitoring of
quality improvement issues.

2. Describe the application of HIM in research.

The first project focused on the development and

implementation of a Web-based reporting system
For collecting occurrence reports in a patient safety
program to reduce medication errors. Results of this
Research project included improvement in quality of
data within the reports, a 230 percent increase in the
Number of reports received, an increase in the number
of intercepted errors from 17.3 percent to 58.2
Percent, and an increase in the number of reported
errors attributed to physicians from 4.5 percent to 16.9
Percent. These results provided evidence of a
heightened level of consciousness regarding patient
safety Issues throughout the entire organization, which
has a direct impact on healthcare practice among
Providers.

The second project is the development of an

educational foundation focused on patient safety and
best Practices to be implemented in the curriculum of
the authors’ institution and surrounding healthcare
Providers throughout the state. The first project served
as an impetus for this second project. Members of
The HIM faculty have been instrumental in dispersing
the patient safety curriculum developed through
Educational modules both within the University Of
Mississippi Medical Centre (UMMC) and at healthcare
Provider sites throughout the state.

The third project is the development of an information

infrastructure linking rural hospitals to the
UMMC, a tertiary care centre. UMMC will serve as a
resource centre for gathering and analysing patient
Safety data. The focus will be on expanding the patient
safety curriculum and using IT in rural hospital

The Expanding Role of the HIM Professional: Where

Research and HIM Roles Intersect 3
Sites throughout the state. A combination of the first
two grant-funded research activities led to
Involvement in these grants currently under
consideration.