DEWITT REHABILITATION & NURSING CENTER

211 EAST 79TH STREET

MANHATTAN, NY 10075

HIT 272 PRACTICUM

SPRING SEMESTER 2015

308 East 175th StreetBronx, New York 10457

TABLE OF CONTENTS

History

Laws and Privacy Issues

Facility and Orientation

Daily Functions

The Practicum experience

Observations of the Director

Quantitative and Qualitative Analysis

Lessons Learned

Conclusion and Final Analysis

Final Thoughts and Questions

Questions and Answers

THE HISTORY OF DEWITT REHABILIATATION & NURSING CENTER

• DeWitt opened their doors in 1967 at 211 E. 79th Street in Manhattan,

New York, and in front of the building has a dog standing in the gap,

ready to aid the senior citizens who urgently need the care. The owner

at the time was Marylin Lichtman DeWitt who has been running DeWitt

Rehabilitation & Nursing Center ever since. Every nursing home has its

problems here and there, but the performance gets a rating of 4 to 5

stars, in which I would say is wonderful!

• DeWitt mission statement: We are passionate about rehabilitation and

nursing care. We constantly strive to provide the greatest services,

treatment options, and enhance the quality-of-life for all of our residents.

We believe the cornerstone of great services in this industry is to have

compassion. We provide customized care solutions and build lasting

relationships.

• In the healthcare industry, physicians, nurses, staff, and all other

members in other departments interact with the HIM Record

Department.

HIM DAILY FUNCTIONS

• Dictated Audio, Voice Recognition, Scanned Charts, Diagnostic Images

• Patient Lab Data, Reference Content, Patient Schedules, Drugs &

Immunization

• History & Allergies, HL7 Interface

• Patient care management

• Healthcare Delivery Organizations

• Law Enforcement Officials

• Education

• Other Medical Departments

• Research

• Public Health and Homeland Security

• Medical Billing & Reimbursement

HIPAA LAWS, PRIVACY, SECURITY

• Health Insurance Portability and Accountability Act (HIPAA) of 1996

restricted access to patient information on a “need to know” basis as it

directly involves the care of the patient in a given legitimate access.

• HIPAA contained provisions that would lead to the development of data

security standards on a national level.

• The HIPAA privacy and security standard were further strengthened

when the Health Information Technology for Economic and Clinical

Health (HITECH) Act was enacted on February 17, 2009.

• Privacy is “the right of an individual to be let alone. In includes

freedom from observation or intrusion into one’s private affairs and the

right to maintain control over certain personal and health information”

(Harman 2006, 634).

• Confidentiality carries “the responsibility for limiting disclosure of

private matters. It includes the responsibility to use, disclose, or release

such information only with the knowledge and consent of the

individual” (Harman 2006, 627-628). Confidential information may be

written or verbal. Security includes “physical and electronic protection

of the integrity, availability, and confidentiality of computer-based

information and the resources used to enter, store, process, and

communicate it; and the means to control assess and protect information

for accidental or intentional disclosure” (Haman 2006, 635).

THE FACILITY AND ORIENTATION

Comforts

We provide a friendly community with a helpful staff. We have 499 beds,

wireless internet access, and the diversity of a community that comes from

all over. We are confident that the patient will feel right at home.

Clinical Services

We provide; IV Therapy, Respiratory Therapy, Chronic Pain Treatments,

Wound Care, Trach Care, Social Services & Support.

Physical Therapy, Occupational Therapy

Activities we provide:

Wireless Internet

Arts and Crafts

Music

Reading Groups

Cards and Games

Religious Activities

Dancing

Outings

Shopping

PRACTICUM EXPERIENCE

• I have learned how to set up the Medical Record Charts for the nurses’

• I have observed and learned how the Coding Supervisor purged records, and

checked for missing signatures and documentation

• I have observed and learned about the Outguide, in which other departments

would have to sign for the PHR, and also the inbox from when they’re returned.

• I have observed, prepared Medical Charts for the “Inside Storage” and for the

Offsite location. I have learned the about the Fax/Copy machine and how to do

the forms that are required.

• I have observed and learned how to file records and retrieve them from the

alphabetical and numeric filing systems.

• I have learned where information goes on the nurses’ unit. I am ready to take

my position as a health information technician.

OBSERVATION OF THE DIRECTOR

• One of the most important things to do in the HIM Department is to

listen and to observe.

• Observation plays a good role in understanding what is required, and

because of the many challenges, observation is a key element in

assisting, doing, and completing the task required.

QUANTITATIVE & QUALITATIVE ANALYSIS

There are analysis for quantitative and qualitative

purposes

Analyst for the quantitative check is to make sure

all documentations are within the guidance of the

HIPAA compliance the do’s and don’ts, or privacy

issues etc.

Analyst for qualitative checks to see if the medical

record has missing signatures, or if there any

weakness with the diagnosis and procedures that

does not fit the description given.

LESSONS LEARNED

• Protect, Secure, and keep Patient Health Records Confidential at all times

• The hierarchy of the healthcare organization

• HIT should know the organizational Chart for all the departments

• Keep a handy guide of the AHIMA Standard Codes of Ethics

• Be professional at all times

• Dress professional with complete attire

• Remember the “Hippocratic Oath” while on the job

CONCLUSION AND FINAL ANALYSIS

• Medical records are vital and serves as a source of information for the

patient, healthcare organizations, the government for statistic purposes,

and for analysis. What makes a good HIT is to adapt to the changes,

following the policies and guidelines as HIM professionals are the

custodians of records.

• HIM are at the center of control when it comes to patient EHR, and it’s

essential that HITs be ready for the use of interoperability in systems of

ICD-9-CM to the ICD-10-CM turnover.

• HIM Departments are in the stage of exploring many new options for the

records department, and as a HIM or HIT there will be plenty of new

roles to be responsible for.

FINAL THOUGHTS

Roles that enlighten my thoughts of being a HIT consists of being a:

• Coding Specialist as a CCS.

• My final thoughts as a HIT - I look to advocate, uphold, and defend the individual’s right

to privacy and the doctrine of confidentiality in the use and disclosure of information.

• Preserve, protect, and secure personal health information in any form or medium and

hold in the highest regards health information and other information of a confidential

nature obtained in an official capacity, taking into account the applicable statutes and

regulations.

• Facilitate interdisciplinary collaboration in situations supporting health information

practices.

• Refuse to participate in or conceal unethical practices or procedures and report such

practices to supervisor.

ANSWERS & QUESTIONS

Contact: Daryle Cook Tel. (646)678-4609 Email cook_daryle@yahoo.com