Health Information Management Technology 4th Ed By Sayles -Test Bank

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Health Information Management Technology 4th Ed By Sayles -Test Bank


Health Information Management Technology 4th Ed By Sayles -Test Bank

Health Information Management Technology

An Applied Approach

Fourth Edition







Instructors Manual

Chapter 2

Purpose and Function of the
Health Record






Lesson Plan

Background and Instructional Delivery

Every HIT student should understand the fundamentals and purpose of the health record including its various uses, its users, its various components, and the roles and responsibilities of an HIT professional in regard to the record. This chapter begins by presenting the basics of the health record. It is important for students to understand the fundamental purposes of a health record and how their work supports these purposes. Throughout this chapter, emphasize the importance of the work of the HIT professional in ensuring that the purposes of the health record are fulfilled. Instructors should discuss the current transition from paper-based health records to electronic formats, noting the challenges HIM professionals face in working with hybrid health record systems. Instructors can also reinforce the history of the profession by emphasizing that the traditional work of HIT professionals was and is today to support the basic functions of the health record, regardless of record format.


The chapter introduces students to the users of health records. This discussion underscores the importance of the work of the HIT professional in supporting critical roles and users of the data and information contained in the health record. The chapter also provides students with their first introduction to the concepts of privacy, confidentiality, and security of health information. Instructors should discuss the critical role HIT professionals play as patient advocates to safeguard an individuals health information from unauthorized access.


The topics in this chapter set the stage for introducing the quality attributes that must be associated with the health record; namely, accuracy, accessibility, comprehensiveness, and consistency. The role of the HIT professional in contributing to these quality attributes and data quality improvement should be emphasized.


Chapter Outline

Learning Objectives

Key Terms


Theory into Practice

Purposes of the Health Record

Primary Purposes

Secondary Purposes

Users of the Health Record

Individual Users

Patient Care Providers

Patient Care Managers and Support Staff

Coding and Billing Staff


Other Individual Users



Law Enforcement Officials

Healthcare Researchers and Clinical Investigators

Health Science Publishers and Journalists

Government Policy Makers

Institutional Users

Healthcare Delivery Organizations

Third-Party Payers

Medical Review Organizations

Research Organizations

Educational Organizations

Accreditation Organizations

Governmental Licensing Agencies

Policy-Making Bodies

Functions of the Health Record

Storage of Patient Care Documentation


Data Quality Improvement





Guidance in Clinical Problem Solving

Paper Records

Hybrid Records

Electronic Records

Results Management

Order-Entry/Order Management

Clinical Decision Support

Real-World Case #1

Real-World Case #2




Learning Objectives

  • Define the term health record
  • Understand the purposes of the health record
  • Identify the different users of the health record and its importance to each user
  • Explain the functions of the health record
  • Apply quality characteristics to the collection and maintenance of health data and databases
  • Clarify the differences in paper-based, hybrid, and electronic methods in fulfilling the functions of the health record
  • Discuss the attributes of security, access, flexibility, connectivity, and efficiency in fulfilling the functions of the health record
  • Identify the roles and responsibilities of health information management professionals in the development and maintenance of health record systems

Key Terms


Accreditation organization

Aggregate data

Allied health professional

Centers for Medicare and Medicaid

Services (CMS)

Coding specialist



Data accessibility

Data accuracy

Data comprehensiveness

Data consistency

Data currency

Data definition

Data granularity

Data precision

Data quality management

Data relevancy

Data timeliness

Diagnostic codes

Electronic health record (EHR)

Health record

Hybrid health record


Integrated health record format


Personal health record (PHR)


Problem-oriented health record format

Procedural codes

Quality improvement organization (QIO)



Source-oriented health record format

Third-party payers


Utilization management organization




Theory into Practice and Real-World Case

Use the Theory into Practice section and/or the Real-World Case to initiate student discussion of the material in the chapter. The questions in the Check Your Understanding sections located throughout the chapter also can be used to stimulate class discussion.


Guest Speakers

Invite a guest speaker from a local or state health department or from an association that is collecting and aggregating healthcare data for a specific demographic population. Have the speaker describe the overall purpose of the project, how data is collected, how it is analyzed, and the reporting structure and format. Have students ask questions related to data collection and analysis. Discuss ways in which the project could be improved using the AHIMA data quality management model.


Field Trip or Site Visit

Arrange for a site visit to a local hospital or clinic to expose students to how a health record is created and used for treatment and reimbursement purposes. Have students write a summary of the activities witnessed (for instance, admission of a patient, nurses reviewing/documenting in the record, physicians reviewing/documenting in the record, or discharge processing of the health record). Have students discuss those functions that were paper-based and those that were electronic. Discuss the benefits/changes to the process if all functions were electronic.



Use the enclosed PowerPoint slides as a lecture guide.


Analysis Using Web Resources

Have students prepare a table of the quality attributes of a health record. For each attribute, have them identify potential adverse effects on patient care and facility operations that may occur should each of these attributes not be present. Have students identify what their role is as an HIT professional for ensuring the quality attributes in the health record.


Quality Attribute Definition Potential Adverse Impact Role of HIT Professional



Have students put together a trivia game. For this chapter, have students develop 10-15 cards on the purposes of the health record and quality characteristics of the health record.



Real-World Case Discussion #1 Questions

  1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR?

Data integrity refers to the state of data being complete, accurate, consistent, and up-to-date. Use of copy/paste functionality has the potential to destroy data integrity if the data or information copied from a previous patient encounter into the current patient encounter is no longer accurate.


  1. How does copy/paste functionality affect reimbursement?

Healthcare reimbursement is based on codes that identify diagnoses and procedures for a particular patient stay. Coding specialists assign these codes based on documentation in the health record. If the documentation in the health record for a particular encounter is inaccurate due to an inappropriate use of the copy/paste functionality, then it is likely that reimbursement will be inaccurate for that particular encounter.


  1. What measures can a hospital take to improve data integrity in their EHR while still achieving their goal of streamlining the documentation process?

The hospital could:

  • Incorporate functionality into the electronic documentation system that permits use of the copy/paste functionality only when appropriate. For example, copy/paste is an appropriate functionality for creation of a discharge summary, but it is not appropriate for creation of a physical exam report.
  • Create a way for copied material to be readily identified. This could be done by putting copied text in a special color or highlighting its source on the screen and on printed reports.
  • Create electronic links to documentation in other encounters, eliminating the need for copy/paste functionality.

Real-World Case Discussion #2 Questions


  1. What impact can a hybrid record have on patient care?

Because a hybrid health record can be scattered in multiple locations, there must be a way to retrieve all information for patient care. Failure to do so will result in the physician and other healthcare providers not having all of the patient information. This could result in problems with patient care as decisions would be made without complete information. The quality of patient care could suffer if medications are ordered that are contraindicated or duplicate tests are performed.


  1. How might the hybrid record change health information management?

The HIM department needs to identify the location of all components of the health record. All of these components must be managed, which would include security, disclosure, retention, and other data management functions.


  1. How might a hospital overcome some of the issues created by the hybrid record?

            There should be policies and procedures in place that address where the various components are stored, as well as how to bring them together for patient care, release of information, and other purposes.


Application Exercises

  1. Go to the AHIMA website ( and search for articles related to data quality management, the AHIMA data quality improvement model, or the AHIMA data quality management model. Choose two articles that discuss the subject. Write a paragraph on the key points for HIM professionals to consider in the design of electronic data collection systems.

Students may write about any of the characteristics of the AHIMA data quality management model or the EHR documentation improvement model discussed in the chapter. It is important that the students response reflect the interrelationships of the quality characteristics and the quality management domains.


  1. Go to the AHIMA website ( or another health-related site and search for articles related to functions of the electronic health record. Select two articles to read, and then write a paragraph about each that discusses the projected or achieved benefits of these functions to healthcare delivery.

Answer varies based on articles chosen.


  1. List and define the six attributes associated with storage of patient care documentation.
  • Accessibility: all patient care information should be available 24 hours a day, seven days a week to legitimate users
  • Quality: patient care information in the health record should be accurate
  • Security: patient care information in the health record should be kept private
  • Flexibility: health record data should be meaningful and able to meet the needs of all users
  • Connectivity: health record data should be able to be exchanged through electronic communication linkages and health information exchanges
  • Efficiency: health record data should be captured in structured formats and analyzed efficiently



  1. Go to the AHIMA website or some other health-related site and search for articles related to the uses and users of health records. Select two articles to read and write a paragraph on each. Why did you select each article? What do you think is important about each article?

      Articles selected by students should reference uses and users of health record data, not general information related to healthcare. Student responses should demonstrate an understanding of who uses health record data, what type of data is used, and why the data is important to the user.


  1. Discuss the responsibilities of health information management professionals in the development and maintenance of health record systems. What are some new roles for HIM professionals in the future?

HIM professionals are responsible for the entire life cycle of the health record including planning, processing, distribution, maintenance, storage, retrieval, archiving, and destruction. These fundamental responsibilities apply to both paper-based systems and computer-based systems. As the transition from paper-based records to electronic health records takes place, roles of the HIM professional are changing accordingly. Some of the new roles for HIM professionals may include:

  • business change manager
  • EHR system manager
  • IT training specialist
  • business process engineer
  • clinical vocabulary manager
  • workflow and data analyst
  • consumer advocate
  • clinical alerts and reminders manager
  • clinical research coordinator
  • privacy coordinator
  • enterprise application specialist


Additional references on this topic include:

AHIMA e-HIMTM Task Force. 2004. Practice Brief: The Strategic Importance of Electronic Health Records Management. Journal of AHIMA 75(9).

Cassidy, B., and S. P. Hanson. 2005. Practice Brief: HIM Practice Transformation. Journal of AHIMA 76(5).

Tegen, A., et al. 2005. Practice Brief: EHR Career Opportunities: Sample HIM Job Descriptions. Journal of AHIMA 76(5).


  1. Interview a HIM professional on the differences in working in a paper, hybrid, and/or electronic health record environment. Write a summary of your interview.


Most HIM Directors would be able to talk to students on this issue as most are operating a hybrid environment in todays healthcare system.

Questions that the student may ask include questions about:

  • How their current system works
  • How the hybrid record has changed their department
  • What their future plans are with regard to the implementation of the EHR
  • Problems that they encountered
  • How they resolve the problems encountered

Review Quiz

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.


  1. Which of the following is a secondary purpose of the health record?
  2. Document patient care delivery
  3. Assist caregivers in patient care management
  4. Aid in billing and reimbursement functions
  5. Generate a report to be used in performance improvement


  1. Which of the following is an institutional user of the health record?
  2. Patient care provider
  3. Third-party payer
  4. Coding and billing staff
  5. Government policy maker


  1. How do patient care managers and support staff use the data documented in the health record?
  2. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
  3. Communicate vital information among departments and across disciplines and settings
  4. Generate patient bills and/or third-party payer claims for reimbursement
  5. Determine the extent and effects of occupational hazards


  1. Which of the definitions below best describes the concept of confidentiality?
  2. The right of individuals to control access to their personal health information
  3. The protection of healthcare information from damage, loss, and unauthorized alteration
  4. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
  5. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information


  1. Which of the following statements does not pertain to paper-based health records?
  2. They have a built-in access control mechanism.
  3. They are kept in locked storage areas that are accessible only to authorized staff.
  4. They are logged out according to the organizations prescribed procedure.
  5. They are forwarded to the appropriate service area when needed for patient care purposes.



  1. Which of the following is an advantage offered by computer-based clinical decision support tools?
  2. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature.
  3. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends.
  4. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives.
  5. All of the above


  1. The hospital where I work is transitioning to an EHR. In the meantime, we have part of

the health record electronic and part is still paper. This concept is known as:

  1. Integrated health record format
  2. A hybrid record
  3. A resident record
  4. Integrated health record format


  1. Critique this statement: Data and information mean the same thing.
  2. This is a true statement.
  3. This is false as data is used for administrative purposes and information is used                                for clinical purposes.
  4. This is a false statement as data is raw facts and figures and information is
    data converted into a meaningful format.
  5. This is a true statement as information is raw facts and figures and data is                              information converted into a meaningful format.


  1. Which of the following statements does not pertain to electronic health records (EHRs)?
  2. EHR technologies and systems must not intrude on the patient and provider relationship.
  3. EHRs are filed in paper folders.
  4. In the United States, a national health information infrastructure is being designed to support EHRs.
  5. Clinicians use computer keyboards when documenting in the EHR.


  1. Which of the following is a secondary purpose of the health record?
  2. Support for provider reimbursement
  3. Support for patient self-management activities
  4. Support for research
  5. Support for patient care delivery



  1. Use of the health record by a clinician to facilitate quality patient care is considered:
  2. A primary purpose of the health record
  3. Patient care support
  4. A secondary purpose of the health record
  5. Patient care effectiveness


  1. Use of the health record to monitor bioterrorism activity is considere:
  2. Primary purpose of the health record
  3. Secondary purpose of the health record
  4. Patient use of the health record
  5. Healthcare licensing agency function


  1. How do accreditation organizations use the health record?
  2. To serve as a source for case study information
  3. To determine whether the documentation supports the providers claim for reimbursement
  4. To provide healthcare services
  5. To determine whether standards of care are being met


  1. How do research organizations use the health record?
  2. To examine results of experimental protocols
  3. For reporting of communicable diseases
  4. To investigate domestic violence
  5. To manage disability insurance benefits


  1. Attorneys for healthcare organizations use the health record to
  2. Support claims for medical malpractice
  3. Protect the legal interests of the facility and its healthcare providers
  4. Plan and market services
  5. Locate missing persons


  1. Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using?
  2. Source-oriented health record
  3. Integrated health record
  4. Patient-oriented health record
  5. Problem-oriented health record


  1. Inaccurate data recorded in the health record could:
  2. Compromise quality patient care
  3. Contribute to incorrect assumptions by policy makers
  4. Invalidate research findings
  5. All of the above


  1. The term used to describe expected data values is
  2. Data definition
  3. Data currency
  4. Data precision
  5. Data relevancy


  1. Protection of healthcare information from damage, loss, and unauthorized alteration is also known as:
  2. Privacy
  3. Results management
  4. Security
  5. Data accuracy


  1. Since we implemented a new technology, we have eliminated lost orders and problems
    with legibility. What technology are we using?
  2. Computerized physician/provider order entry
  3. Electronic health record
  4. Results management
  5. Clinical decision support


  1. The paper-based health record format that organizes all forms in chronological order is known as the:
  2. Problem-oriented health record
  3. Integrated health record
  4. Patient-oriented health record
  5. Source-oriented health record


  1. Critique this statement: The health record documents services provided by allied health professionals and a patients family.
  2. This is a true statement.
  3. This is a false statement as the health record only documents physicians care.
  4. This is a false statement as the health record only documents care provided by patient families.
  5. This is a false statement as the health record documents the care provided by healthcare professionals.


  1. An individuals right to control access to his or her personal information is known as:
  2. Security
  3. Confidentiality
  4. Privacy
  5. All of the above


  1. When all required data elements are included in the health record, the quality characteristic for ______ is met.
  2. Data security
  3. Data accessibility
  4. Data flexibility
  5. Data comprehensiveness


  1. Critique this statement: Patient care managers are individual users of health records.
  2. This is a true statement.
  3. This is a false statement as they do not require patient information to do their job.
  4. This is a false statement as they require patient information to do their job.
  5. This is a false statement as patient care managers are institutional users.

Test Bank

with Key

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.


  1. Which of the following best describes the most important function of the health record?
  2. Communicating instructions between physicians and nurses
  3. Providing information to support reimbursement claims
  4. Storing patient care documentation
  5. Providing information to support managed care


  1. Who are the primary users of the health record?
  2. Clinical professionals who provide direct patient care
  3. Insurance companies that cover healthcare expenses
  4. Billers in the healthcare facilitys business office
  5. Patients and their families


  1. Which of the following elements is not a component of most patient records?
  2. Patient identification
  3. Clinical history
  4. Financial information
  5. Test results


  1. Healthcare information systems need to exchange information. This linkage between
    systems is referred to as:
  2. Connectivity
  3. Efficiency
  4. Flexibility
  5. Security


  1. Which of the following is not a characteristic of high-quality healthcare data?
  2. Data relevancy
  3. Data currency
  4. Data consistency
  5. Data accountability


  1. Which of the following represents an example of data granularity?
  2. A progress note recorded at or near the time of the observation
  3. An acceptable range of values defined for a clinical characteristic
  4. A numerical measurement carried out to the appropriate decimal place
  5. A health record that includes all of the required components


  1. What is the defining characteristic of an integrated health record format?
  2. Each section of the record is maintained by the patient care department that provided the care.
  3. Integrated health records are intended to be used in ambulatory settings.
  4. Integrated health records include both paper forms and computer printouts.
  5. Integrated health record components are arranged in strict chronological order.


  1. Critique this statement: Electronic health record systems have the same access control
    requirements as paper-based record systems.
  2. This is a true statement.
  3. This is a false statement as the requirements for the electronic health record are less stringent.
  4. This is a false statement as the requirements for the electronic health record are more stringent.
  5. Electronic health records are inherently less secure.


  1. Critique this statement: Paper-based record systems are not flexible enough to meet all of the needs of every health record user.
  2. This is a true statement.
  3. This is a false statement as paper-based record systems are more flexible than electronic systems.
  4. This is not an issue as flexibility of the health record is not important to the quality of the patient care and administrative needs of the organization.
  5. This is a false statement as paper-based systems may not be flexible but they still meet all of the needs of every health record user.


  1. Match the following health information terms with their definitions. (Definitions may be used more than once or not at all.)

b          privacy

a          confidentiality

c          security

  1. The expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
  2. The right of individuals to control access to their personal health information
  3. The protection of the privacy of individuals and the confidentiality of health records
  4. The protection of healthcare facilities from vandalism and theft


  1. Which of the following best describes data accuracy?
  2. Data are correct.
  3. Data are easy to obtain.
  4. Data include all required elements.
  5. Data are reliable.


  1. Which of the following best describes data completeness?
  2. Data are correct.
  3. Data are easy to obtain.
  4. Data include all required elements.
  5. Data are reliable.


  1. Which of the following best describes data accessibility?
  2. Data are correct.
  3. Data are easy to obtain.
  4. Data include all required elements.
  5. Data are reliable.


  1. Data definition refers to the:
  2. Meaning of data
  3. Completeness of data
  4. Consistency of data
  5. Detail of data


  1. Dr. Jones entered a progress note in a patients health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
  2. Data completeness
  3. Data relevancy
  4. Data currency
  5. Data precision


  1. The admitting form of Mrs. Smiths health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smiths birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smiths health record?
  2. Data completeness
  3. Data consistency
  4. Data accessibility
  5. Data comprehensiveness


  1. I need an information system that will provide assist physicians in diagnosing and treating patients. The system that I need is:
  2. Results management
  3. Order-entry/order management
  4. Clinical decision support
  5. Electronic health record


  1. I have been asked to list institutional users of the health record. Which one of the following would I include in my list?
  2. Blue Cross and Blue Shield
  3. The patient
  4. FBI agent
  5. AHIMA

Health Information Management Technology

An Applied Approach

Fourth Edition







Instructors Manual

Chapter 18

Principles of Organization and
Work Planning



Lesson Plan

Background and Instructional Delivery

This chapter presents an overview of organizational principles and supervisory management. In some cases HIT students may take a course on supervisory management in their HIT program. In those cases this chapter can be used as a foundation for a capstone course that serves as a review of supervisory principles while at the same time brings together all other elements of HIT practice into framework that helps the student to synthesize the practice of health information management.


The decision-making model presented in the chapter can be used as the organizing framework for the class. As example, instructors may wish to teach the concepts of management and supervision through the use of cases that the student solves using the decision making framework from this chapter. For either a capstone course or an introduction to management, this model is ideal for developing problem solving skills.


Instructors may also wish to use parts of this chapter, particularly the section on organizational principles, with chapter 12 on healthcare delivery systems.


The chapter begins with organizational principles and discusses organizational structures and tools. The information provides students with an introduction to the use of organizational charts and reiterates the importance of mission and vision statements that was presented in the chapter on performance improvement. This is an opportunity to study real life organizational charts, mission, and vision statements from local clinical sites.


The next section talks about the various levels of management from supervisory through executive and board management. The functions of management are presented including planning, organization, and control. A framework for decision making is presented. This framework or model is excellent for use as a tool to help students define and analyze problems. Instructors might want
to use this decision-making model as a central part of their course in presenting problems or case studies for students to solve. The problem-solving framework is also an excellent way to conduct a capstone course.


Human resources management is covered in the next section. Of particular importance to the HIT supervisor are position descriptions, performance/practice standards, and policies and procedures. Sections on recruitment and retention, new employee orientation and training, and team building are all essential to the supervisors role.


The chapter concludes with principles of supervision. Importance of coaching and mentoring, performance management, conflict management, and grievance management are all covered as well as staff development.


A small section on budgeting and financial control is presented so that students understand the importance of the budgeting process.


Chapter Outline

Learning Objectives

Key Terms


Theory into Practice

Principles of Organization

Nature of Organization

Organizational Structure

Management Levels

Roles of Teams and Committees

Organizational Tools

Organizational Charts

Mission, Vision, and Values Statements



Human Resources

Leadership Principles

Recruitment, Orientation, and Training

Staff Retention

Delegation of Authority and Empowerment

Performance Management

Conflict Management

Employee Development

Fundamentals of Work Planning

Strategic Planning

Operations Planning

Expense Budgets

Supply Management


Work Analysis and Design

Performance and Quality Improvement for HIM Functions

A Model for Quality Improvement

Change Management


Real-World Case



Learning Objectives

  • Distinguish between hierarchal and bureaucratic organizational structures
  • Identify the roles of the three basic levels of management
  • Explain the function of common organization management tools including mission, vision, and values statements; policies; procedures; and organizational charts
  • Describe the functions of authority, responsibility, and accountability
  • Discuss the fundamentals of leadership
  • Discuss the benefits of teamwork in an organization and identify the steps in creating an effective team
  • Describe the usual practices for recruitment, orientation, and training for new employees
  • Identify effective steps in conducting an interview
  • Describe the usual practices for staff retention
  • Explain how position descriptions, performance standards, and staff schedules are used as tools in human resource management
  • Describe how job descriptions are used in recruitment and hiring
  • Discuss the elements of performance management
  • Explain the relationship among performance standards, performance review, and performance counseling
  • Identify the key steps the supervisor should take in performance counseling or in taking disciplinary action
  • Discuss ways that conflict can be minimized in the workplace
  • Explain techniques used for staff development
  • Distinguish between strategic and operational planning
  • Describe the quality improvement cycle and the steps for change
  • Explain the budget process and how it relates to organizational and department goals and assumptions
  • Describe tools used for planning and managing staff resources
  • Explain the processes used in work analysis and design
  • Identify the methods for supply management


Key Terms




Action steps

Ad hoc committee




Board of governors

Board of trustees

Budget assumptions


Career planning

Chain of command

Change management

Conflict management

Delegation of authority

Developing stage

Direct costs

Disciplinary action

Employee orientation

Environmental assessment


Executive management

Executive manager

Executive sponsor


Fixed costs


Grievance management


Human resources

Indirect costs

Inventory control

Job redesign

Middle management

Middle managers

Mission statement

Mixed costs

Monitoring stage


Operational plan


Organizational chart

Performance counseling

Performance evaluations

Performance management

Performance standards


Planning stage


Position descriptions


Process redesign

Progressive discipline

Quality improvement


Rating stage





Rewarding stage

Staff retention

Staffing analysis

Standing committees


Strategic planning

Supervisory management

Supervisory managers

Supply management

Systems thinking

Team norms

Values statement

Variable costs

Vision statement

Work schedules

Workflow analysis




Use the enclosed PowerPoint slides as a lecture guide.


Theory into Practice and Real-World Case

Use the Theory into Practice section or the Real-World Case to initiate student discussion of the material in the chapter. The questions in the Check Your Understanding sections located throughout the chapter also can be used to stimulate class discussion.


Guest Speakers

Invite a manager of an HIM department to class to talk about the organizational structure of the facility where they work and to demonstrate how the HIM department fits into this structure. Discussion should also center on the HIM organizational structure and the rationale for this structure. Have a discussion on the mission and value statements of the organization and the HIM department. How do these guide the operation of the facility and the department?


Ask a human resources representative to talk on issues of human resources management. What does the HR department do? How does the HIM department interface with the HR department? How are position descriptions developed? How is grievance management handled?


Have a guest speaker discuss how a budget for an HIM department is developed. Ask the speaker to emphasize how data collection to support the budget is done? What role do the supervisors in the department plan in preparation of data for the budget?



Develop or obtain an operational plan for an HIM or other health information-related department. Discuss the contents of the operational plan. How does the operational plan reflect the mission and values of the organization? How does the operational plan fit with the strategic plan of the organization? What goals must be met in the operational plan? How does the budget fit in with the operational plan?




Real-World Case Discussion Questions

  1. Consider what attributes you would consider important in a candidate

            Students should consider education, skills, coding test score, and any other attribute that you would expect in a coder.


  1. Carefully review the applicants resume. Do they meet the minimum requirements Consider making a list that matches requirements to the applicants qualifications.

            It might be useful to set up a qualifications checklist or spreadsheet with a 0 to 1 rating scale (0 = clearly does not meet to 5 = clearly meets) for each factor within the qualifications section. This will also make it easier to compare applicants when deciding which applicants to interview.

            Rating Scale:  0 = clearly does not meet qualification

                                    3 = minimally meets qualification

                                    5 = clearly does meet qualification


Qualification Resume of Stephen Johnson Resume B
Minimum associates degree in health services discipline 0  
Formal HIM education with national certification: RHIT or RHIA preferred 0  
Coding certification required from AHIMA or AAPC 0  
Minimum of 5 years progressive coding or coding review experience in ICD9-CM, CPT, and HCPCS 0


Claims processing and/or data management experience desirable 0  
Good oral and written communication skills 3 written  
Comprehensive knowledge of the APC structure and regulatory requirements 0  
Past auditing experience desirable 0  
Strong training background in coding and reimbursement desirable 0  
Total rating 3  


  1. As a new supervisor, what should you do to prepare for this job search?

Options include:

  • Talking to human resources about the process, what questions can be asked, what questions cannot be asked
  • Asking other supervisors/managers for suggestions
  • Reviewing resumes
  • Developing a list of questions
  • Determining information that should be shared with applicants (responsibilities, hours, and such)


  1. How will you measure the candidates skills?

The candidate can take a coding test or the interviewer can ask questions that determine the interviewees knowledge of coding rules.


  1. How are you going to assess whether the candidate will fit into the current dynamics of your group?

The interviewer should take note of personality of the interviewee as questions are answered. Questions could also be asked about how the interviewee handles situations, as well as questions that asks for examples of the interviewees relationships with coworkers and more.


Application Exercises


  1. Prepare your resume and complete a job application for a position that is advertised in the newspaper or on the web. Consider how the resume and application should reflect your qualifications for that unique position.

            Instructor guidance required.


  1. In groups of three, practice role-playing an interview. As a team, prepare the interview questions. One person plays the part of interviewer, one plays the role of the candidate, and one observes the interview and takes notes.

            Instructor guidance required.


  1. Identify the types or categories of revenue and expenses that would be required in a release of information function within a hospital or clinic. What assumptions are necessary before starting?

            If ROI is outsourced then an entirely different budget process may occur based on the outsourcing contract. If ROI is done by staff, then the following categories may apply:

            Revenue: copying fees recovered, which may be a single line item on the budget or may be separated by type of requestorlegal, insurance, and such, or by type of charge, copies, retrieval, and the like

            Expenses: salary and benefits, supplies, copier lease (if not a capital budget expense) software licensesif the ROI process is supported by an computer application


            Knowledge that must be gathered before starting:

  • Whether the service will be provided by staff or outsourced
  • If outsourced what staff may still be requiredchart pulls, receptionist, handling patient walk-ins
  • Volume of requests
  • Staffing levels required to meet turnaround requirements
  • Operational or system changes either in the ROI system, or in the electronic availability of information that will effect ROI processing
  • Any increase or decrease in centralization of this function


  1. Write an essay on a previous supervisor with whom you have worked. Consider the leadership qualities he or she possessed. What human resources tools did this supervisor use in his or her position? How effective was your training and orientation? What lessons did you learn from this experience?

            Instructor guidance required.


  1. Conduct a class discussion on the challenges that managers face today. Are there local issues that complicate or streamline their jobs? What current challenges would a manager face in an HIM position in the coming year? How would a manager prepare for these challenges?

            Instructor guidance required.


  1. Prepare a staff development plan for a coding staff for the coming year. Consider the types of training available. Prepare a budget for staff development.

            Consider both the maintenance of competence as well as professional development. Some resources will go toward keeping staff technically up to date with the code changes and with new rules and guidelines. Also, consider continuing education that keeps coding staff current on the latest procedures and techniques done within your facility that may impact coding. Also, consider providing training based on the feedback from internal or external audits. Additionally, coding staff may need or want professional development in other related topics like HIM, electronic health records, general computer skills, or supervisory or interpersonal skills. After considering needs a prioritized list of what training will be helpful in establishing a budget. Then look at training opportunities that may be available at low cost, or no cost. Another consideration is the amount of time away from their production responsibilities. This may impact your accounts receivables if all of the coders are out at a two-day conference and no provision has been made to replace their productivity. Resources students can use to prepare the budget may include AHIMAs website, state or local meeting costs, and resources from other associations or for profit groups.


Review Quiz

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.


  1. Managers are:
  2. Held responsible for handling the organizations resources
  3. Required to perform every job in the organization
  4. Always effective leaders
  5. Not allowed to make mistakes


  1. The practice of management is:
  2. Not affected by new technologies
  3. The same all over the world
  4. The same as it was 50 years ago
  5. Influenced by the context of the organization


  1. Systems thinking:
  2. Is an objective way of looking at ideas and processes
  3. Is outdated and no longer applied in management
  4. Involves planning for computers and technology
  5. Can only be effectively applied to the budget process


  1. A graphic representation of the organizations formal structure is called:
  2. The budget
  3. The mission statement
  4. An organizational chart
  5. Organizational values


  1. The mission statement:
  2. Is updated regularly as part of the strategic planning process
  3. Never changes as it describes what the organization does
  4. Is the same for every healthcare facility
  5. Does not contain information about the organizations customers


  1. Supervisory managers are primarily responsible for:
  2. Developing the organizations policies and procedures
  3. Setting the organizations future direction
  4. Establishing the strategic plan
  5. Monitoring everyday performance


  1. Developing, implementing, and revising the organizations policies is the role of:
  2. Senior managers
  3. The board of directors
  4. Supervisory managers
  5. Middle managers


  1. Ultimate responsibility for the operation of healthcare organizations lies with:
  2. Senior management
  3. The board of directors
  4. All employees
  5. Supervisory managers


  1. Planning, organizing, controlling, decision making, and leadership are the functions of:
  2. The board of directors
  3. Human resources
  4. Management
  5. Supervision


  1. Strategic planning is primarily concerned with:
  2. How the organization will respond to changes in the environment
  3. The budget
  4. Setting organizational policies
  5. Making sure the organization complies with laws and regulations


  1. _____ is not a step in strategic planning.
  2. Analyzing budget variance reports
  3. Developing or revising the values statement
  4. Developing specific action steps for the upcoming year
  5. Officially documenting the boards approval


  1. Within an organization it is the supervisors role to determine:
  2. How staff will be organized
  3. Strategic priorities
  4. The overall budget assumptions
  5. How the work will be accomplished by the team


  1. In modern management theory, control is most important when applied to:
  2. Developing the organizational chart
  3. Getting staff to do their work
  4. Processes and other resources
  5. Developing an initial budget


  1. The director of the department is Bob. Sally, the coding supervisor and five other supervisors, report to Bob. Tim and 10 other coders report to Sally. This describes what management concept?
  2. Chain of command
  3. Systems thinking
  4. Organization
  5. Job design


  1. Strengthening others by sharing information and power is a characteristic of:
  2. Supervision
  3. Management
  4. The organizational chart
  5. Leadership


  1. A summary of the position, a list of duties, and the qualifications required to perform the job are all elements of a(n):
  2. Orientation plan
  3. Performance review
  4. Position description
  5. Schedule


  1. Performance standards are used to:
  2. Communicate performance expectations
  3. Assign daily work
  4. Describe the elements of a job
  5. Prepare a job advertisement


  1. Position descriptions, policies and procedures, training checklists, and performance standards are all examples of:
  2. Human resource tools
  3. Organizational policies
  4. Strategic plans
  5. Items on a training checklist


  1. Procedures should be complete enough so that:
  2. There is no need for policies
  3. There is never any need to improve the process
  4. There is no need to train a new employee
  5. Anyone generally competent for that position can perform the task


  1. The departments orientation checklist would not include a:
  2. Review of communication policies
  3. Discussion of problem employees
  4. Description of how to request time off
  5. Review of departmental goals


  1. During training, the employee should be:
  2. Allowed to work without supervision
  3. Expected to make no mistakes
  4. Encouraged to ask questions
  5. Evaluated for productivity


  1. Teams often fail to succeed when:
  2. The leader dominates the team
  3. The team has chosen an effective leader
  4. The team members care about the outcomes
  5. Differences of opinion exist within the group


  1. Setting a clear deadline is an important step in:
  2. Budgeting
  3. Delegation
  4. Strategic planning
  5. Schedule development


  1. Discovering each individuals talents and maximizing them is the role of the:
  2. Team members
  3. Senior manager
  4. Board of directors
  5. Coach


  1. Periodic performance reviews:
  2. Encourage good performance
  3. Take the place of annual reviews
  4. Are the only opportunity to discuss performance
  5. Are only important when there are problems


  1. Disciplinary action:
  2. Should vary based on whom the employee reports to
  3. Cannot be taken when employees are unionized
  4. Should be taken whenever there is a performance problem
  5. Should be documented at each step


  1. Constructive confrontation is one form of:
  2. Budgeting
  3. Planning
  4. Performance evaluation
  5. Conflict management


  1. Grievance procedures:
  2. Do not concern the supervisor
  3. Vary with each individual
  4. Are defined in the union contract
  5. Are the same in every work setting


  1. On-the-job training:
  2. Is one option for staff development
  3. Is only used for new employees
  4. Involves formal classroom lectures
  5. Uses simulations as a learning tool


  1. During times of change, it is important for the supervisor to:
  2. Be less available
  3. Hold on to the vision
  4. Avoid discussing the change with staff
  5. Stop delegating decision making to others


  1. The budget:
  2. Is the financial plan for the coming time period
  3. Always begins January first
  4. Is done once a year and then forgotten
  5. Usuall

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