Description of Role and Function of Patients Record Managers and Chart Coders
Effective patient records management is indispensable to coordinating and controlling operations within our medical center. Each patient should be registered and, as a result accurate information should be included into our computer database.
Our director of patient records is aware of the roles and responsibilities and, therefore, his/her major function consists in classifying, regulating, and sorting out the medical charts. More importantly, our patient records manager is prone to compile computer-based medical records. In this respect, center is oriented on creating automatic information maintenance rather than on developing paper-based reports.
Both patient record manager and chart coder are responsible for managing and controlling medical documentation provided within a health care setting. Therefore, these managers should work in cooperation for enhancing control and improving the quality of information exchange. Specifically, they should inform each other about the existing problems and provide immediate solutions to eliminating those inconsistencies.
Observation and Activities
Due to the fact that our hospital applies to innovative approaches and technologies, the introduction of iPad recording and information exchange is much more effective than a traditional paper-based recording method.
This equipment is used to facilitate the information processing and enhance accurate coding of patient records for providing correspondent reimbursement for treatment sessions. In fact, electronic medical record systems are approved in the majority of hospitals throughout the United States and outside it. European countries also recognize a number of benefits of using a computer database.
The research conducted by Laerum (2001) proves that the electronic methods of information storage are quite effective irrespective of the different computer systems involved into data processing. In the course of interview, the medical records managers agree that direct communication with patients is more effective for fulfilling the medical charts accurately.
Therefore, most of the nurses from our hospital prefer examining patients directly to communicating with them via telephone. Hence, accuracy and transparency of the recorded information directly depend on the styles of communication between patients and health care professionals. In this respect, the doctor of patient records should be directly involved in controlling the quality of the information received from other departments.
The process of billing and reimbursement is also important for ensuring effective management and control of costs and benefits within the organization. Most importantly, our managers are accountable for the financial effects of their operations that also contribute to managing medical charts (Wang et al., 2003).
In addition, much attention should be paid to the consideration of advantages of electronic systems over the paper-based traditional approach. Wang et al. (2003) have proved that computer-based information systems are much more cost-effective in comparison with the accepted conventional methods.
Primary Roles and Functions Related to Nursing and Patient Services
Once the doctor of patient records has received the information about the clients, the primary responsibility imposed on him/her involves insurance of information safety.
In order to provide safety and confidentiality of the information included into the medical database, the patient records manager receives data directly from other health care department systems to eliminate clutter and minimize the inaccuracies.
Similar to medical records managers, chart coder should be accountable for financial benefits and reimbursements systems with regard to the information received from the medical cards. In this respect, the reviewer has a direct access to financial statements and reimbursement systems of our hospital. According to Wang et al. (2003), a cost-benefit analysis is indispensable to regulating financial operations connected to the implementation of electronic medical information systems.
Record management directly correlates with improving the computer system programs for compiling and classifying patient information. The research studies provided by Ting et al. (2011) demonstrate that system maintenance and performance, as well as user-friendliness, is the main condition for introducing collaborative medical information exchange, as well as for enhancing patient safety through visualization of real-time information about medical processes.
Therefore, the primary purpose of our patient record specialist is to provide a solid platform for patients’ registration and for appointment of a doctor in an automatic, self-service regime. The retrieval of treatment selection and medical diagnoses should also be handled effectively to eliminate biases. This field of functions is of primary significance because it identifies the level of safety and insures the proposed services.
Insights of Leadership Behavior and Style
The introduction of effective computer-based records systems should be congruent with the improvement of communication between patients and physicians, as well as effective management of patient information (Taylor, 2010, p. 178).
In this respect, our hospital considers the introduction of electronic patient record a powerful tool for improving accuracy, eliminating redundancy, and introducing higher levels of patient safety. Our organization realizes, however, that the importance of maintaining paper-based documentation is enormous since these materials should be stored in case of legal trials and subpoenas.
Judging from the above-presented consideration, both our patient record manager and medical charts reviewer apply to a mixed approach to control and determine the level of transparency and availability of the information to health care personnel and outside entities (Taylor, 2010). They consider confidentiality and patient safety a priority and, therefore, they are aware of the importance of following legal and ethical regulations, as presented in the generally accepted norms.
Although both managers are toughly connected in terms of responsibilities they take, their leadership styles, as well as behavior patterns, slightly differ. In particular, our patient record manager applies to an affiliative type of leadership, implying coaching and introduction of norms and templates for fulfilling the medical charts.
In contrast, our chart coder is more likely to use a solid frame while presenting reimbursement codes of patient treatment. Specifically, the leader should focus on the organizational effectiveness and excellence to maintain high quality of the services provided.
Summary
Judging from the above-presented interviews and gained experience, much information has been received to define the lapses in managing information and enhancing patient safety and quality of health care services. Specifically, I have learned a number of theoretical and practical approaches to managing financial and patient records effectively. These methods are directed primarily at introducing electronic systems of data storage and developing effective cost-analysis techniques.
Our managers, therefore, were able to explain that patient safety largely depends on the way the computer-based systems are handled and evaluated. In addition, they also realize that, in order to eliminate human errors and maintain the accuracy and confidentiality of information, strict control and observance of documentation processing should be implemented.
Finally, the interview has also led to the assumption that the reimbursement and intervention procedures can be significantly improved with the introduction of modern software controlling the information flow.
References
Laerum, H., Ellingsen, G., & Faxvaag, A. (2001). Doctor’s use of electronic medical records system in hospitals: cross sectional survey. BMJ. 323, 1344-1358.
Taylor, B. (2010). Effective Medical Leadership. Canada: University of Toronto Press.
Ting, J. L., Tsang, A. C., Ip, A. H., & Ho, G. S. (2011). Professional practice and innovation: RF-MediSys: A radio frequency identification-based electronic medical record system for improving medical information accessibility and services at point of care. Health Information Management Journal, 40(1), 25-32.
Wang, S. J., Middleton, B., Prosser, L. A., Bardon, C. G., Spurr, C. D., Carchidi, P. J., et al. (2003). A cost-benefit analysis of electronic medical records in primary care. The American Journal of care. 114(5), 397-407.