Overview: For the final project, you will imagine that you are the health information manager for the newly formed Quality Regional Healthcare LLC. The chief information officer (CIO) has tasked you with developing a training manual on information governance to provide guidance to the medical coders and clinical professionals of the new hospital organization. In the training manual, you will introduce the overall importance of information governance to this newly formed organization and explain the organization’s current data-capture and distribution techniques. You will provide examples of common documentation and classification mapping errors found in patient health records and discuss the implications of these errors. Finally, you will examine how the organization shares health information internally and externally and establish methods to improve interoperability and the successful execution of health information exchange (HIE) between hospitals.

Tip: Before you begin to develop your training manual, you must ensure that you have all of the background information necessary by reading the provided case scenario. This scenario will provide background information about your new organization, its strategic goals, and its need for the training manual you have been tasked to create. Throughout the course, you will complete milestones to draft pieces of your training manual. Then, in Module Nine, you will compile and revise the drafts, add additional information to complete pieces not yet drafted, and create a full training manual.

Prompt: In this milestone, you will draft the section of your training manual related to clinical mapping and documentation of electronic health records (EHRs). Using the provided sample electronic patient health records, identify the common coding and documentation errors and discuss the larger implications of these errors.

To begin this assignment, analyze the three provided electronic patient health records (Record One, Record Two, and Record Three) using the EHR Chart Documentation Worksheet.

Tip: Complete the worksheet for each record to ensure you have a full picture of the extent of the mapping and documentation errors.

Once you have analyzed the patient health records, you will develop a portion of the training manual to present these errors to the staff of Quality Regional Healthcare LLC, and to explain the larger implications of these errors.

Tip: To assist you in creating examples of appropriate clinical mapping to show the staff of the organization, you may want to use the I-MAGIC resource.