Unit 6 Assignment Instructions
Unit outcomes addressed in this Assignment:
Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.
Course outcome addressed in this Assignment:
GEL-1.02: Demonstrate college-level communication through the composition of original materials in Standard English.
HI253-4: Summarize the features of health information systems used for quality coding practices.
AHIMAs Professional Coding Approved Program (PCAP) Mapping:
Domain I. Data Content, Structure & Standards (Information Governance)
Subdomain I.A Classification Systems
1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)
o Classification Systems
ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)
o Taxonomies
Clinical Care Classification (CCC)
o Nomenclatures
CPT, DSM, RxNorm
o Terminologies
LOINC, SNOMED
EHR and Coding Resources Comparison:
Situation:
You are the coding supervisor at a major acute care hospital. The hospital administration has been studying payment and outcome metrics for the institution, and realizes that the current electronic health records system may be outdated. You have been asked to create a report that answers the following question: What EHR and coding resources would you recommend to the hospital administration to ensure that the most current ICD-10-CM/PCS codes are in use in your healthcare facility? Your report should compare at least 3 EHR systems that you have been exposed to in this course (for example Nuance Clintegrity, 3M Encoder, VistA) or worked with in the past. Your comparison should include features such as coding resources, advantages/disadvantages, and computer system requirements for each system. Your report should include your final recommendation out of the three systems you review and the rationale for your decision. Your comparison report should be well-ordered, logical, and unified, as well as original and insightful. Your report should include a comparison table that summarizes your findings. It is not necessary to follow paragraph style in the comparison table.
