Having a complete medical record is every HIM’s goal – yet somehow this often seems unattainable. Are portions missing? Has everything been dictated or signed? Have antiquated terminologies been used? Who is responsible for ensuring the completeness and integrity of the medical record is preserved? The answer is far broader than most HIM professionals envision. The entire organization is responsible. And not just to our own departmental governing polices but as a whole for the safety and security of the patient.
In this presentation I will detail the organizational approach we have launched to help preserve and enhance the medical record utilizing new training programs, advanced technologies and integrating additional data quality initiatives.