Virtual Professional Practice Experience Assignment 7 (15 hours) Statistical Analysis using Excel

VirtualProfessional Practice Experience

Assignment 10 (20 hours)
Data Abstracting Module
Associate/ Bachelor Level

Competencies:

 Apply diagnosis/procedure codes according to current guidelines (I.A.1)
 Analyze the documentation in the health record to ensure it supports the diagnosis

and reflects the patient’s progress, clinical findings, and discharge status (I.B.1)
Roles incorporating the skill:

 Coder
 Clinical Documentation Improvement Specialist

Delivery areas:

 Healthcare providers
 Insurance companies
 Government agencies

Presentation(s):  HIM Department Tour Video
 Video: Mary Beth Haugen Video Interview
 Video: A day in the life of a coder

Detailed Project
Instructions:

 Access the 15 records to be coded in the Solcom application in the VLab. If you are a first-
time user of the VLab, you should have received information for how to set up your
account from AHIMA. This lesson assumes you have already set up your account and are
now a returning VLab user.

o Open the Getting Started in Solcom EDMS resource
o Click the link to enter your user name and password (HRZ001, AHIMA#77)
o Search for each record by entering the patient number in the Master Patient Index

Masterid field and then clicking on enter. Patient numbers to be used for this
lesson are:

 328391
 300282
 348927
 388967
 398761
 322039
 324789
 330909
 320102
 394857
 330017
 333061
 398275
 308882
 334562

 Before starting the coding process, review the abstract form to identify the kind of data you
will be required to enter for each record. For each record coded you will complete an
abstract form, entering all requested data. Add notes to the abstract form to comment on
missing data or data that was difficult to find in the record.

 Code each of the 15 records by using the 3M or other ICD-10-CM encoder in VLab. When
coding the records, make sure to code and identify the CCs (complication & co-
morbidities).

 Use an abstract form for each chart and enter data in the fields on the abstract form to
include Medical Record Number, admit date, discharge date, point of origin, discharge
status, attending physician, principal dx code, principal procedure code, other codes, co-
morbidities and complications. There are required formats and drop-down selection boxes
for some data that is to be entered.

 Write a summary report identifying areas where information was missing or hard to find.
From the notes you made while abstracting identify possible causes for the missing,
incorrect or hard to find information. Also indicate your recommendation for a solution for
corrective action to be taken. Provide comments on what you learned from this project and
what was most difficult for you to do. Submit this along with the completed abstract form
for each record.