HINM 271 - Professional Practice Experience II

• Apply facility policies and procedures to ensure accuracy of health data.
• Conduct analysis per facility guidelines to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings and discharge status.
• Summarize and verify timeliness, completeness, accuracy and appropriateness of data and data sources for patient care, management, billing, reports, registries, and/or databases.
• Monitor and apply organization-wide health record documentation guidelines.
• Use and maintain electronic applications and work processes to support clinical classification and coding.
• Assess and ensure accuracy of diagnostic and procedural groupings.
• Validate coding accuracy using clinical information found in the health record.
• Identify and resolve discrepancies between coded data and supporting documentation.
• Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs.
• Interpret and apply facility policies and procedures for access and disclosure of personal health information.
• Organize and release patient-specific data to authorized users
• Identify and use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement and imaging.
• Apply facility policies and procedures to the use of networks, including intranet and Internet applications, to facilitate the electronic health record, personal health record, public health and other administrative applications.
• Support and participate in the planning, design, evaluation and support for electronic health records.

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