Term Paper: Day of Shadowing Interview

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Nurse Shadowing

The author of this response will describe the observations from interviewing and shadowing two different medical professionals. One is a director of medical records and the other is a medical records review/chart coder. Since both of these positions, in some manner for form, deal with medical records the observations and outcomes of this project should be very illuminating. There will be several sections to this report. A description of the roles that each person engages in will be described, a brief summary and review of what the author of this report sees during the shadow will be discussed, an analysis of the primary roles and functions will be touched upon, any relevant insights that were gained during the above will be mentioned, and there will lastly be a summary of the learning experiences engaged in during the session.

Role Description

Obviously, the two roles are similar in nature but the level of responsibility is quite different. The Director of Patient Records is the highest position that pertains directly to the storing, insuring and management of patient records whereas the reviewer/chart coder is more of an analyst position that looks at particular situations and dynamics. The director managed higher-level functions such as the major decisions of how daily operaiotns occur and how to handle any major issues that might arise. The medical records reviewer/charge coder is more of an operations/analysis position that does not deal with the high-end or emergency functions of medical records but the latter is indeed important in terms of keeping the daily flow of operations smooth and efficient.

To delve down a bit further, the Director of Electronic Records is a very high-level position in that the amount of responsibility and accountability for the job is off the scale in many ways. Any major events or issues that happen that pertain at all to medical records will solely or entirely involve the intervention and decision-making of the director. Conversely, the medical reviewer/coder position is important as well because if that position's person is not trained to do an efficient and correct job, it will only hurt the overall operations of the department and daily tasks and this would fall on the aforementioned director as well. In short, the coder/reviewer is responsible for the normal daily tasks of the job while the director oversees people like the reviewer/coder and rectifies problems with personnel behavior, execution and changes that come up as time goes on, both planned and unplanned.

The writer of this report obviously did not personally "get hands dirty" or see a lot of computer screens due to HIPAA and other relevant regulations, yet another part of the job that affects both the coder/reviewer and the director (but the latter a lot more than the former because that person is held more accountable for mistakes/problems) but both people, in their own way, helped manage process and tasks in a way to keep information flowing smoothly, correctly and in a way that insured the best quality of care and the best overall efficient operations.

As far as insights that the author of this report gained, there are several. First, exquisite attention to detail is an absolute must for both positions. Being careless, lackadaisical or otherwise willfully or unconsciously disengaged is career suicide and this is true in either position. Carelessness can lead to lower quality of care and this can translate to patient aggravation or even death so it is imperative for all of the cogs in the machine, the director just as much as the analyst/coder, to be functioning in unison and playing from the same handbook.

Another observation is that while the medical records people are not quite as involved in emergency situations like the nurses and doctors are, the emergency room people in particular, the medical records people play a pivotal role in allowing those front-line professionals to be able to do their job and provide care in a correct and efficient manner. In short, if a coder or the director is not doing their job, it will eventually affect the front-line medical staff in one way or another and that can be deadly or at least extremely aggravating depending on how that all manifests itself.

Next, issue with medical records is not entirely within the control of the medical records staff, but still has to be and must be dealt with nonetheless, is that patients are often unwilling or unable to provide correct and current information. This can be because they are unconscious or it can also be due to things like mental illness or aloofness. While this may seem to be the purview of just doctors and nurses, the use of templates, checklists and the like are key in ensuring nothing important is missed or glossed over and this is where medical records comes into play. The director helps to make sure the proper templates and guidelines are there and the records review and coder uses the templates along with the nurses and doctors that actually assess the patients.

In other words, even people that work in administration play a pivotal role in quality of care because of the impacts that can be borne upon the front-line professionals that depend on the efficacy and completeness of the medical record solution that is in use. Just as nurses and doctors not abiding by procedure and process can be deadly or at least unfortunate, the same thing can happen with medical records professionals of all levels. The different common manifestations are obviously different but it is true nonetheless.

To loop in some external sources and thought patterns on medical records, it is clear that electronic medical records are the wave of the future and that, if done correctly, are inherently more effective and efficient than doing paper-based records. However, this is not to say that electronic health records cannot be a huge headache that can be bungled and otherwise botched. Any complex information system, which an electronic health records apparatus certainly is, can lead to a giant kerfuffle if done incorrectly. As such, it is imperative that all levels of personnel, both inside the records department and outside of it, are trained on how to use the system and it should be consistently verified that use of the system is being done in the right ways, at the right times and consistently over time (Sheridan, 2012).

On that same note, one sentiment (although not specific to the hospital where the shadowing occurred) is that nurses and other major medical personnel tend to be older, rather than younger, and this can have a strong bearing on the acceptance and embracing of technology and this can be a challenge in an environment and in a society that is becoming increasingly technical and advanced. As such, this requires hiring and retaining of the best people possible to enforce and embrace the electronic health records system because people that are unwilling or unable to learn the system and use it effectively can be a liability to a hospital or doctor's office (Middleton et al., 2013).

In terms of a summary of the overall learning experience gained with the shadowing, the author of this report can offer a few quick observations. First, the medical records sphere is not for everyone and this is even true of seasoned information technology and/or medical professionals. Anyone in this field must be vigilant, on top of their game and willing to be in a job that is all business all of the time rather than a job that is slow-paced or even mundane. However, for a person that is interested in the field, has a very strong attention to detail and is it-savvy, this job can be a great fit and the amount of job security and opportunities for someone that is… [END OF PREVIEW]

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