WGU C816 - Task 1 Advancements in
Clinical Documentation for Digital Records
Issues with clinical documentation in Hybrid Record:
• Delays in accessing patient records due to paper-based records.
• Incomplete or missing documentation leading to deficiencies in medical records.
• Manual screening and entry of paper records causing inefficiencies and errors.
• Difficulty tracking and managing deficiencies, leading to revenue cycles issues.
• Risk of lost or misplaced paper documents affecting patient care and outcome. Solutions
with Fully Digital Records:
• Real time access to patient information for healthcare providers.
• Direct entry of patient data into the system reduces the reliance on paper records.
• Automated deficiency tracking and alerts for incomplete records
• Improved organization and accessibility of records, enhancing patient care.
• Preservation of health and financial information without the risk of accidental deletion.
Changes in Roles of Existing HIM Staff
• Scanning Date Entry Staff: Transitioned to roles focusing on quality assurance
and support for digital documentation entry. They will ensure the accuracy and
completeness of electronic records, troubleshoot any technical issues, and provide
training and support to healthcare providers on the new system.
• Deficiency Tracking Staff: Reassigned to roles overseeing automated deficiency
tracking systems. They will monitor and manage deficiencies flagged by the
system, coordinate with healthcare providers to address incomplete records
promptly, and ensure compliance with regulatory requirements related to medical
documentation.
Reverse Roles and Responsibilities in SDLC:
• HIM Project Manager: Responsible for overseeing the entire transition process from
the hybrid to fully digital record. This includes planning, coordinating with IT and
clinical staff, managing resources, and ensuring the project stays on schedule and within
budget.
• HIM Training Coordinator: In charge of developing and implementing a
Clinical Documentation for Digital Records
Issues with clinical documentation in Hybrid Record:
• Delays in accessing patient records due to paper-based records.
• Incomplete or missing documentation leading to deficiencies in medical records.
• Manual screening and entry of paper records causing inefficiencies and errors.
• Difficulty tracking and managing deficiencies, leading to revenue cycles issues.
• Risk of lost or misplaced paper documents affecting patient care and outcome. Solutions
with Fully Digital Records:
• Real time access to patient information for healthcare providers.
• Direct entry of patient data into the system reduces the reliance on paper records.
• Automated deficiency tracking and alerts for incomplete records
• Improved organization and accessibility of records, enhancing patient care.
• Preservation of health and financial information without the risk of accidental deletion.
Changes in Roles of Existing HIM Staff
• Scanning Date Entry Staff: Transitioned to roles focusing on quality assurance
and support for digital documentation entry. They will ensure the accuracy and
completeness of electronic records, troubleshoot any technical issues, and provide
training and support to healthcare providers on the new system.
• Deficiency Tracking Staff: Reassigned to roles overseeing automated deficiency
tracking systems. They will monitor and manage deficiencies flagged by the
system, coordinate with healthcare providers to address incomplete records
promptly, and ensure compliance with regulatory requirements related to medical
documentation.
Reverse Roles and Responsibilities in SDLC:
• HIM Project Manager: Responsible for overseeing the entire transition process from
the hybrid to fully digital record. This includes planning, coordinating with IT and
clinical staff, managing resources, and ensuring the project stays on schedule and within
budget.
• HIM Training Coordinator: In charge of developing and implementing a
