Clinical Documentation Improvement

Unit 4 Assignment: Analysis of Health Information Management within a Local Clinic and Clinical Documentation Improvement Programs Unit outcome addressed in this Assignment: Take part in the planning, design, selection, implementation, integration, testing, evaluation, and support of health information technologies. Course outcome assessed in this Assignment:HI150-2: Outline the critical stages of developing a health information system. Notes: For the clinic selected, consider the information needs of the customer. Distinguish the Clinical Documentation Improvement (CDI) software needs that would be seen within the clinic from the CDI needs across the healthcare continuum. Refer to Unit 3 and 4 Discussion Boards and seminars for more information and conversation regarding this analysis.  For the clinic selected and the Clinical Documentation Improvement (CDI) software selected, apply your knowledge of database architecture and design for the clinic’s needs. Please include a brief explanation on the needs of data dictionaries, data warehousing, and overall database architecture (OLAP v. OLTP). Include a listing of the database items that would need to be gathered, their definitions, and how they are utilized. Instructions: Assume you are an Office Manager for a small to medium-size physician practice clinic. Review the Readings from Unit 3 and Unit 4 including the information on Systems Selection, Implementation, and Appendix A RFI/RFP reporting format in addition to the discussion boards and seminar presentations for Units 3 and 4. Deliverable:  Prepare a 3-4-page report that outlines: The needs of the clinic as it relates to Clinical Documentation Improvement Software including What is Clinical Documentation Improvement? What, if any, barriers exist to implementing the software? What is the role of the HIM professional? The needs of the larger healthcare community/continuum as it relates to Clinical Documentation Improvement Software. Research at least three Clinical Documentation Improvement software vendors and review their systems. At a minimum, include the following information in comparing the vendors in a table format: 

What are the benefits of the system as listed on their web page? What kind of facility utilizes the vendor’s system?Is there a coding encoder system component part of the system or available? Are there any advantages of their system over others (as listed on their web page)? Any information available in prices, demonstrations, free trials, and implementation.  Could you “see” inside the system on the vendor’s web site? Conclude your review with a statement of which system you would purchase as a small office physician practice and why? In your table or in an additional table, outline the database dictionary terms and definitions commonly used in the implementation of Clinical Documentation Improvement software in a Health Information Department. What items should be included in the reporting database according to the needs of the clinic as well as the broader health information community/continuum of care? Are there multiple definitions available for singular terms? Assignment Requirements Prepare a 3-4-page report that follows the conventions of Standard American English (correct grammar, punctuation, etc.) addressing the above questions and issues and in a Microsoft Word document, where appropriate. Include your table comparing the CDI vendors and data dictionary items as either a standalone document or embedded in the Word Document. The body of your document should be at least 1000 words in length. Quoting should be less than 10% of the entire paper. Paraphrasing is necessary. Students must cite and reference at least 4 credible sources from the University Library. Your writing should be well ordered, logical, and unified, as well as original and insightful. Your table(s) (see example below) may be created in Word, PowerPoint, or Excel. Be sure to visit APA Central to assist you with meeting APA expectations for written Assignments. Your work should display superior content, organization, style, and mechanics. Furthermore, all sources used should be properly cited using APA. For more information on Clinical Documentation Improvement read this:https://en.wikipedia.org/wiki/Clinical_documentation_improvement

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