442 Health Information Administration IV Professional Practice Standards PDF

# 442 Health Information Administration IV ## Professional Practice Standards ## Introduction: * Quality * How do we measure quality? * Standards * AHIMA * American Health Information Management Association * Professional Practice Standards ## With regard to AHIMA, why such standards were develo...

# 442 Health Information Administration IV ## Professional Practice Standards ## Introduction: * Quality * How do we measure quality? * Standards * AHIMA * American Health Information Management Association * Professional Practice Standards ## With regard to AHIMA, why such standards were developed? Because of the escalating costs of health services have created an environment in which health care managers are increasingly being held accountable for the quantity, quality, timeliness and cost of the services rendered under their direction. These practice standards represent an established role model against which you can compare the status of the medical record department you direct and your performance as director. ## The practice standards reflect the professional competencies necessary to assure quality medical record services. ## Areas of professional practice: Eight major areas of professional practice for managing patient care information in a health care facility have been identified and a standard articulated for each. These areas include: * Content of the Medical Record * Patient Care Data * Confidentiality * Health Information Management * Storage and Retrieval * Management and Supervision * External Requirements and Standards * Quality Assessment/Improvement Systems. ## Structure of the Professional Practice Standards manual (Partly attached) * **STANDARDS MODEL** * **PRACTICE AREA**   * **RATIONALE** * **FUNCTIONS** * **GUIDELINES** * **EVALUATION MECHANISMS** ## The Purpose Statement defines objectives and states the reason why standards are desirable/necessary. ## Applications illustrate various uses for standards in general, as who can use them and how they can be used. ## Practice Standards reflect the professional competencies necessary to assure the quality of medical record/information services. ## The Rationale statements state the reason why each standard should be considered a standard of record practice. ## The Function Statements demonstrate the practice standards in action. ## Quality Guidelines assess the effectiveness and efficiency of work performance consistent with practice standards and function statements. ## Evaluation Mechanisms are individualized tools to be used to assess areas of individual knowledge, system operations and performance, so the practice standards are used as dynamic aids in achieving the highest quality of professional practice. ## The Bibliography includes references used/suggested for standards development (including the Educational Resource Document, Roles and Function Project, Essentials for MRT and MRA programs and other literature pertinent to the function statements). ## Ways in which the checklist can be utilized: * The evaluation checklist may be utilized in several ways: * A self-evaluation completed by the department director. * An internal review completed by a departmental committee or by each supervisor in the department. * A peer review mechanism completed by the director of medical records for a local facility. * An external review completed by several department heads within the facility. ## Advantages and disadvantages of the different ways in which the checklist can be utilized: * Self-evaluations and internal reviews may lack objectivity, for assessing something one is responsible for and deeply involved in is often threatening. We may be reluctant to uncover problem areas or inadequacies for they may be a result of our own poor judgment. * On the other hand, some self/internal evaluators are more critical than outside evaluators, and those involved in the evaluation process may learn a great deal from the experience, for one of the surest paths to personal and professional growth is learning by examining. ## Peer reviews and external reviews should be more objective for the reviewers are not so close to the situation. It may be difficult, however, to obtain competent objective outside reviewers, for other local medical record practitioners may hesitate to identify weaknesses because of friendship or uncertainty about the validity of their findings. This problem may be resolved by making it a group project among the local directors of medical record departments, so the group evaluates each medical record department in the community. ## An advantage to using other department heads as evaluators is that it is a very effective means of educating other departments about the medical record department. ## Those who use the practice standards as an evaluation tool must also remember that is it necessary to analyze variations from the standards. One must search for the cause of the deficiencies before developing action plans to correct such deficiencies.