Free essay on nursing journal report assignment

Introduction

Medical professionals such as nurses, physiotherapists, and physicians, do not necessarily have to handle patients for them to practice (Chen et al., 2009). There are instances wherein they may be assigned to do administrative tasks such as maintaining and regulating patient records or keeping everyone’s efforts in every hospital or company department well-compensated instead of clinical duties such as handling and treating patients.

The objective of this essay is to discuss my learning experiences, including my observations, thoughts, and insights regarding the performance of the Director of Patient Records and a Medical Records Reviewer and Chart Coder practicing in a health institution in the local community.

Background

While I was in my over 1620 hours of stay at our local community health institution, I was able to work side by side with one of the greatest Director of Patient Records, and Medical Records Reviewer and Chart Coder in the industry. Their names would not be disclosed in this report as they personally requested me to conceal their identities for confidentiality and privacy reasons. However, I could attest to the truth that they are two of the most professional and honest healthcare administration professionals I have and will ever encounter. For efficiency purposes allow me to call the Director of Patient Records Mr. D and the Medical Records Reviewer and Chart Coder Mr. M.

Director of Patient Records

Our local community healthcare institution is a tertiary hospital that handles approximately 400 different types of patients per day. Now, the hospital has the responsibility to record every detail about any particular patient’s visit for future references and all other kinds of medical reasons (Wilson et al., 2012). Based on these statements, we could safely assume and then prove that there is a need for someone, or in most cases, an entire department, that will safe-keep every patient’s records and make them easily accessible by authorized hospital personnel; otherwise they could be sued by the patient (Pronovost et al., 2008). Things like these are incredibly useful because it is inevitable for a hospital to handle patients who are required to undergo more than one treatment and everything about a patient’s visit including his demographic information, physician’s documentation, and physical examination and ancillary procedures results are included in his patient record. Multiply that to the number of patients that the hospital handles in a day, a week, a month, and a year, and that could be a very big responsibility.

Mr. D was one of the top guys in the particular hospital department suited to the abovementioned job descriptions. As he was doing his job, I noticed a lot of things about the way he does and executes them. During my visit, the hospital was preparing for a huge change that is directly related to Mr. D’s department. They are trying to convert the hospital’s patient-recording environment into an almost completely paperless one. Now, being the Director of Patient Records, Mr. D had to ensure that every existing patient record would be integrated to the new paperless database together with the new ones. Just thinking about the amount of job that would take almost made me jump. Mr. D maintained his composure and simply told me that it’s all part of his job and that he wouldn’t be placed in that position if the higher administrators did not believe he could do those types of job in the first place. At that time, I knew that I was talking to a confident professional who knows everything there is to know about his job and department.

Mr. D was a great leader. He knew that he was not alone and so he called for a scheduled and a well-planned meeting with all the members of the Patient Records Department. He enthusiastically assigned a set of tasks to each of the team members, threw out some words of encouragement, exchanged some laughs with them and then called the meeting adjourned. For over a month, I stayed with Mr. D and his team to observe. When it was already time to leave, I could see that they are still not finished with the whole patient record integration thing because, according to him, of the huge number of patient records that the hospital holds.

Personally, I think Mr. D showed good work ethics and many signs of a good leader. These qualities are rather important in his position because he is not only responsible for safe-keeping existing and incoming patient records; he is also the one responsible for the entire team’s performance.

Medical Records Reviewer/Chart Coder

Administrating a hospital is a complicated and a complex task. There are always a lot of things to be considered apart from ensuring that most, if not all, patients’ health condition improve as a result of the treatments that the physicians and therapists outline and conduct. Other responsibilities of a hospital include computing for every patient’s bill, which most likely depends on the type and number of services used. Generally, this principle is applicable only to private health institutions because government-funded ones generally require minimal to no payments (Lesselroth et al., 2011).
Given that the hospital where I conducted my observations caters to some 400 patients’ medical needs every day, we could assume that that is approximately the amount of job that the Medical Records department has to handle per day. Therefore, it is critically important for this hospital to have a dedicated department responsible for ensuring accurate encoding of values; otherwise, the hospital may receive negative patient feedbacks or worse, be sued.
I was given the chance, a golden opportunity I must say, to observe how Mr. M, Hospital Medical Records Reviewer and Chart Coder works in his workstation for over a month. During that time, I was also able to observe how he works with other members of the team and how his team members work.
Firstly, I would like to put stress on how busy Mr. M is during a normal working day. 400 may be a small number for a medium-sized tertiary hospital but it looked like processing medical records is a very complicated job. On average, it takes Mr. M 15 to a maximum of minutes to process a single patient’s medical record. I asked him what the reason is and he responded by saying that it is his job to ensure that everything in the patient’s medical record and bills assessment is accurate because healthcare services could be costly and not being able to honor discounts and reimbursements simply because of human errors (people from their department’s error) could be devastating for the patients, especially for those who only rely on social services and health insurances for medical expenses coverage. He thoroughly reviews every variable in the records and checks for discrepancies before forwarding them to the succeeding department. I also asked Mr. M if there is any way to automate the process just like what they were doing at the patient records keeping department. Unfortunately, according to him, full automation of medical records reviewing, at least at that moment, is not possible because of the amount of verification and the complexities that the job of being a medical records reviewer and charts encoder entails. Sometimes, patients would complain to the front desk about a certain variable in their medical records that for them, seems questionable. The personnel at the front desk would then verify the complainant’s concern or concerns with Mr. M or any other person from the same department and everything, most of the time, gets settled almost immediately. Yes, there were times during my observation wherein Mr. M or his other team members committed errors but I realized that errors, although practically inevitable, should be avoided at all costs because what’s at stake here is the reputation of the medical institution.

Conclusion

It has been an amazing experience to watch Mr. D and Mr. M do their jobs in their respective departments. I have seen how these two healthcare administrative professionals show their superb work ethics and dedication towards their job, one of the most important requirements to succeed in almost every field. I’ve learned that focus is a very important key. One should always focus on his and not others’ responsibilities. Otherwise, he will not be able to accomplish them. I’ve also learned how difficult and busy a Director of Patient records and a Medical Records Reviewer & Charts Recorder would be.

Works Cited

Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009). The Kaiser Permanente Electronic Health Record: Transforming and Streamlining Modalities of Care. Journal of Health Affairs.
Lesselroth, B., Holahan, P., Adams, K., Sullivan, Z., Church, V., Woods, S., Felderr, R., Shawn, A., Dorr, D. (2011). Primary Care Provider Perceptions and Use of a Novel Medication Reconciliation Technology. Informatics in Primary Care.
Pronovost, P., Berenholtz, S., Goeschel, C., Thom, I., Watson, S., Holzmueller, C., Lyon., J., Lubomski, L., Thompson, D., Needham, D., Hyzy, R., Welsh, R., Roth, G., Bander, J., Morlock, L., & Sexton, J. (2008). Improving Patient Safety in Intensive Care Units in Michigan. Journal of Critical Care.
Wilson, R., Michel, F., Olsen, S., Gibberd, R., Vincent, C., Assady, R., Rasslan, O., Qsous, S., Macharia, W., Sahel, A., Whittaker, S., Ali, M., Letaief, M., & Ahmed, N. (2012). Patient Safety in Developing Countries: Retrospective Estimation of Scale and Nature of harm to Patients in Hospitals. BMJ Group.