Internship objectives

Write a 5-7 page paper addressing objectives that were learned during an internship. All of these objectives may not be addressed.

1. Data Analysis and Management

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a. Abstracting information found in health records

b. Analyze data

c. Maintain filing and retrieval systems for health records

d. Identify anomalies in data

e. Resolve risks and/or anomalies of data findings

f. Maintain the MPI

g. Eliminate duplicate documentation

h. Organize data into a useable format

i. Review trends in data

j. Gather/compile data from multiple sources

k. Generate reports or spreadsheets

l. Present data findings

m. Implement workload distribution

n. Design workload distribution

o. Participate in the data management plan

p. Input and/or submit data to registries

q. Summarize findings from data research/analysis

r. Follow data archive and backup policies

s. Develop data management plan

t. Calculate healthcare statistics

u. Determine validation process for data mapping

v. Maintain data dictionaries

2. Coding

a. Apply all official current coding guidelines

b. Assign diagnostic and procedure codes based on health record documentation

c. Ensure physician documentation supports coding

d. Validate code assignment

e. Abstract data from health record

f. Sequence codes

g. Query physician when additional clinical documentation is needed

h. Review and resolve coding edits

i. Review the accuracy of abstracted data

j. Assign POA indicators

k. Provide educational updates to coders

l. Validate grouper assignments

m. Identify HAC

n. Develop and manage a query process

o. Create standards for coding productivity and quality

p. Develop educational guidelines for provider documentation

q. Perform concurrent audits

3. Compliance

a. Ensure patient record documentation meets state and federal regulations

b. Ensure compliance with privacy and security guidelines

c. Control access to health information

d. Monitor documentation for completeness

e. Develop a coding compliance plan

f. Manage release of information

g. Perform continual updates to policies and procedures

h. Implement internal and external audit guidelines

i. Evaluate medical necessity

j. Collaborate with staff to prepare the organization for accreditation, licensing and certification surveys

k. Evaluate medical necessity

l. Respond to fraud and abuse

m. Develop forms

n. Analyze access audit trails

o. Ensure valid healthcare provider credentials

4. Information Technology

a. Train users on software

b. Maintain database

c. Set up secure access

d. Evaluate the functionality of applications

e. Create user accounts

f. Troubleshoot HIM software or support systems

g. Create database

h. Perform end user audits

i. Participate in vendor selection

j. Perform end user needs analysis

k. Design data archive and backup policies

l. Perform system maintenance of software and systems

m. Create data dictionaries

5. Quality

a. Audit health records for content, completeness, accuracy and timeliness

b. Apply standards, guidelines, and/or regulations to health records

c. Implement corrective actions as determined by audit findings

d. Design efficient workflow processes

e. Comply with national patient safety goals

f. Analyze standards, guidelines, and/or regulations to build criteria for audits

g. Apply process improvement techniques

h. Provide consultation to internal and external users of health information on HIM subject matter

i. Develop reports on audit findings

j. Perform data collection for quality reporting

k. Use trended data to participate in performance improvement plans/initiatives

l. Develop a tool for collecting statistically valid data

m. Conduct clinical pertinence reviews

n. Monitor credentials of physicians to practice in the facility

6. Legal

a. Ensure confidentiality of the health records

b. Adhere to disclosure standards and regulations at both state and federal levels

c. Demonstrate and promote legal and ethical standards of practice

d. Maintain integrity of legal health record according to organization bylaws, rules and regulations

e. Follow state mandated and/or organizational record retention and destruction policies

f. Serve as the custodian of health records

g. Respond to release of information (ROI) requests from internal and external requestors

h. Work with risk management department to provide requested documentation

i. Identify potential health record related risk management issues through auditing

j. Respond to and process patient amendment requests to the health record

k. Facilitate basic education regarding the use of consents, healthcare power of attorney, advanced directives, DNRs and such

l. Represent the facility in court related matters as it applies to the health record

7. Revenue Cycle

a. Communicate with providers to discuss documentation deficiencies

b. Participate in clinical documentation improvement programs to ensure proper documentation of health records

c. Collaborate with other departments on monitoring accounts receivable

d. Provide ongoing education to healthcare providers

e. Identify fraud and abuse

f. Assist with appeal letters in response to claim denials

g. Monitor claim denials/overpayments to identify potential revenue impact

h. Prioritize and distribute the work according to accounts receivable, patient type

i. Maintain the chargemaster

j. Ensure physicians are credentialed with different payers for reimbursement