AHIMA Standards Task Force Members 2016 Name Affiliation Kathleen Addison Alberta Health Services Linda Bailey-Woods Plante Moran DeShawna Hill-Burns Advocate Trinity Hospital Carlyn Multnomah County Department of Assets Susan Clark eHealthcare Consulting Alane Combs Coastal Healthcare Vicki Delgado Kindred Hospital Albuquerque Elisa Gorton St. Vincent's Medical Center Darice Grzybowski H.I.Mentors,LLC Aaron Haskett Sutter Health Sandra Huyck Beaumont Health System Theresa Resurrection University Satyendra Kaith Kaplan Higher Education Group Robin Keeney VHC, Inc. Katherine Lusk Dallas Children’s Medical Center Susan Lucci Just Associates Marcia Matthias Southern Illinois Healthcare Tabitha McDaniel McKesson Lori McNeil Tolley Boston Children's Hospital Sharon Ministry Health Care Neysa Noreen Children's Hospitals and Clinics of Minnesota Sandra Nunn KAMC Consulting Michael Nusbaum M.H. Nusbaum & Associates Ltd.
Quality Requirements Real time patient information verification UML Workflow and Dataflow Diagram (Sequence Diagram) Figure 4 presents the Unified Modeling Language (UML) sequence diagram to demonstrate roles and relationship of the actors (business and technical), workflow and data flow associated with the use case. Figure 4: UML Sequence Diagram: Use Case A1 - Registration of Walk-in/Patient Presentation in ED. Numbers 1-11 indicate the workflow steps.
8. Ability to access information created with legacy hardware and software systems within an organization. In case of impending system obsolescence, information with organizational value should be migrated to currently supported hardware/software and/or converted/migrated into a compatible format from non-compatible media (MAC vs PC) and non-compatible software versions. – See Integrity #5 Step 4 Step 4 9. Ability to access information imported from an external organization by incorporating pertinent content into the organization’s health information system, e.g., by scanning, digitizing and codifying external information, as defined by organization and jurisdictional policies. – See Integrity #5 Steps 4, 8, 9 Steps 4, 8, 9 Health Information Integrity: Business Requirements Checklist Items Use Case 2. Ability to maintain integrity of information to comply with safety, quality of care, and compliance to applicable voluntary, regulatory and legal requirements. – See Compliance #1, #2, #4 Steps 3, 5, 7, 10, 11 Step 3: HIS creates an audit record of the encounter Step 5: Registration staff validates patient information and sign the record with e-signature Step 7: Insurance verifier registrar verifies patient insurance information; contacts payor, if needed; and collects co-pay Step 10: Registration information is uploaded into EHR system Step 11: Audit trail for the personnel and systems involved in patient registration is completed in HIS 3. Ability to maintain integrity of information through adherence to an organization’s policies and procedures, including compliance to retention, archive, and destruction guidelines and requirements. – See Retention #2, #3 3, 5, 10, 11 Steps 3, 5, 10, 11 6. Ability to ensure the integrity of information through reliable system controls that support the Step 3, 4, 8, 9, 10, 11 Steps 3, 4, 8, 9, 10, 11
HIM Practice Checklist: <Name> - TO BE DEVELOPED Business Requirement List of Items by Actor, by Workflow Step List of Documents/Records/Data by Actor, by Workflow Step Conformity Assessment: <Name> - TO BE DEVELOPED References -- TO BE DEVELOPED Patent Registration Use Cases Use Case Name: Patient Registration – Inpatient Admission Scheduled via Call or in Person & Admit Actors Business Actors: Patient, Referring/Ordering Physician, Scheduler, Insurance Verifier Registrar Technical Actors: EHR system & Registration-Admission, Discharge and Transfer System(R-ADT) # of Step Workflow Steps Record, Documents and Data Scheduling 1 Scheduling includes one or more of the follow activities; pre-admission scheduling, physician referrals, physician ordered, or patient presents at hospital scheduling/admissions department to schedule admission. Pt demographics (name, DoB, address, Insurance ID) Admission demographics (enterprise medical record number, attending physician name, date, time, service, admitting diagnosis, chief complaint, anticipated procedure) 2 Registration Staff - identifies patient and schedules the admission 3 Registration staff queries patient about diagnosis and treatment, assigns codes for diagnosis and procedures ICD-10 CM & PCS codes 4 Registration Staff - validates patient information, verifies medical insurance coverage, requests insurance admission authorization insurance authorization number Patient Admission 5 Patient presents at hospital 6 Registration staff asks patient to sign consents, acknowledgements, and authorizations, patient is given notices and information in accordance with policy. Notice of privacy practices, consent to treatment, admission agreement, consent directive, and advanced directive 7 Registration staff enters updated patient information and scans documents into EHR Updated medical record or encounter record? 8 Registration staff initiates either room assignment or bed assignment Updated medical record or encounter record? Entry Condition EHR - registration Exit Condition EHR - triage Quality requirements Real time patient information verification