HAK1009
Knowledge Activity: Analyzing for Chart
Deficiencies (Associate)
Student instructions
1. If you have questions about this activity, please contact
your instructor for assistance.
2. You will review the chart of Virginia Amberg to
complete this activity. Your instructor has provided you
with a link to the Analyzing for Chart Deficiencies (AS)
activity. Click on 2: Launch EHR to review the patient
chart and begin this activity.
3. Refer to the patient chart and any suggested resources to
complete this activity.
4. Document your answers directly on this activity
document as you complete the activity. When you are
finished, you will save this activity document to your
device and upload this activity document with your
answers to your Learning Management System (LMS).
The activity
One of the duties of your HIM position is to perform chart
analysis for your hospital to ensure that documentation is
complete, accurate and timely. The facility has recently
purchased Chart Tracking software that includes the ability to
, flag charts within your EHR for deficiencies based on specific
criteria. This new software will be implemented in the coming
months. With the improved analysis process this new software
will provide, the medical staff would like standardized
documentation requirements that must be completed by the
healthcare team.
Your HIM Director provided you with a list of some of the
documentation requirements that she would like the software
to analyze. She has also given you a sample patient to
perform a manual chart analysis for her review: Virginia
Amberg. The Director will present the software, along with
your analysis as an example, to the medical staff at their next
meeting in preparation for the software rollout.
Review the documentation in Virginia Amberg’s EHR and
answer the questions below.
Questions
1. Complete the chart element checklist below,
indicating whether the provided requirement is
complete, incomplete, deficient or not applicable
(N/A) for the specific EHR tab specified in Virginia
Amberg’s EHR. Be sure to review the entire EHR. An
item should be considered:
o Complete if the item is in the EHR and documented in
the required location/tab.