1. Shirlee Linke
Practicum Portfolio
HIT 272
Spring 2016

2. •Obtain employment in Medical Records
•Explore training as Compliance Auditor
•Pursue education to become Compliance Auditor
•Obtain employment within the Department of Health, as a
Compliance Auditor

3. Practicum Experience HighlightsObjectives and Goals
•Morning Meeting
•Census
•Medical Records
•Auditing
•Release of Information
•Disclosure Log
Compliance
•Pursue Associates of Applied Science degree in Health
Information Technology
•Summer 2016-Anticipated graduation from DeVry University
•2016-Registerd Health Information Technician (RHIT)
Certification Examination

4.  Observed use of Hybrid Medical Record System
 Use of electronicandpapermedicalchart
 Format and filing is according to facility needs
 Differentfacilities require differentinformation
to providetreatment; filing istediousbutnecessary
 Thinning Records keeps only current orders in the chart
 Coding is done using electronic record
 Organization is vitally important in Medical Records
It takes an organized, detailed-oriented individual who can workindependentlyto perform
the functions of a Medical Records Technician
Medical Records

5.  Admission Audit
o Performed 3 days after admission to confirm required documentation and
assessments were completed
o Use of electronic and paper record
 Discharge Audit
o Performedwithin30 daysafterdischargeto confirm alldocuments weresigned and
all paperwork has been returned to the record
o Paper record only
 Quarterly Audit
o Performed on current patients’ medical charts only
o Use of electronic and paper record
This isQuantitativeand Qualitative Analysis! I was responsible to check that all required
documents werein therecord, theinformation wasaccurate, and thatitwascompleted within
the required time.
Audits

8.  PatientRequests
o 48 hoursto respond
o RiskManager, Administrator,andLawyerquickreview
 AnotherHealthcareFacilityRequests
o Requestmustbemadeon letterhead
o Muststatewhatinformation isneeded
o Doesnotneedto bereviewed priorto release
o Used forcontinuum of careto thepatient
 Third-PartyRequests
o Requestmustbea written request
o Mustcontainallpatient’sinformation
o Mustbeaccurate
o Electronic and Paperrecordsarecopied
o Mustbereviewed extensivelyby RiskManager, Directorof Nursing, Administrator,
and Lawyerpriorto release
o 30 daysto respond to request
o Requestormustpay a feefor therecord
Release of
Information

10.  Morning Meeting
o Providesthefacility’sdailycensus
o DepartmentHeads providedailygoals
 QAPI
o Quality Assuranceand Performance Improvement
o Leadershipresponsibility
o Developan Approach
o FacilitySelf-Assessment
o IdentifyPrinciples
o DevelopPlan
o ConductAwareness
o DevelopStrategyto collectand usedata
o IdentifyGapsand Opportunities
o PrioritizeQuality
o Plan,Conduct and Document
o TakeAction
Facility Meetings

13. Activity Log by TCO for HIT272
DeVry University
Health Information Technology Practicum
Student’s Name Shirlee Linke Dates of Affiliation 2/29/16 to 4/21/16
Facility Silver Lake Nursing Center Practicum Director Theresa Oliphant
Date Activity Details TCO Comment(s)
3/4
3/8
3/22
4/5
4/7
4/12
4/15
4/18
Census Report
Auditing
Close discharged records
Thinning charts
Pre-authorization
1 Hybrid system
CAA (comprehensive worksheet)
Minimum Data Set (MDS)
3/4
3/22
4/5
4/7
4/15
4/18
Auditing 2 Quantitative and qualitative analysis
Admission Audit-quantitative
Closed Audit-both (must be done within 30 days of
discharge/expire/transfer)
Quarterly Audit-both; done on current patients (paper and
electronic is used)
3/11
4/15
Audits
Disclosure logs
4 Audits are recorded on a registry form to confirm all
information is provided; if not, a copy is provided to each
dept with highlighted info needed
Disclosure logs are necessary to log information for
requested records; information is kept separate from medical
record and available for review/audit
4/7
4/15
Patient Record Requests 5 Patient can request record; must be provided within 48 hours
Healthcare facilities request records for continuum of care
4/19
4/21
HIT Manual 6 Provides information on policies and procedures for Medical
Records coordinator in the facility
3/11
3/18
Release of Information 7 Must be requested my authorized person; must be accurate;
must be review by Risk Manager, Administrator and facility
lawyer prior to being released; there is a fee associated with
receiving a record
4/18 Facility hardware and software 8 Facility uses PointClickCare (PCC) to enter patient
information, orders, assessments; codes are displayed in this
system
3/29 Morning Meeting; QAPI 9 Morning Meeting is a great way to start the day; reviews
daily activities at the facility and the census for the day
QAPI is a meeting held with all depts to provide info to
improve quality and performance

14. DeVry University HIT272
Health Information Technology Practicum Journal
Name: Shirlee Linke
Date Function or
Work Area
Activities Performed or Observed Time
Spent
What was gained from the
experience?
2/29
Medical Record Basics of SNF records dept; does not
code; uses hybrid system;
6 hours Organization is very important
3/4
Census Review daily census to see if anything has
changed; discharged; expired; transferred
1 hour Census is the start of the day;
provides what charts need to be
closed
3/4 Audit Auditing closed charts 5 hours Need to be detail-oriented; all
orders must be signed; patient’s
name must be on both sides of 2-
sided forms
3/8
Closing and
New Admission
Closing a medical record for discharged,
or expired patients; making New
Admission charts
6 hours Closing a chart is just pulling
paperwork from paper record to be
audited. Then a New Admission
chart should be put on floor
3/11
Patient Record
Request
Requests were made by patient and
healthcare facility for discharged patients
5 hours Only pull requested documentation;
patient requests by the patient must
be provided in 48 hours; these
requests do not need to be
reviewed by the lawyer
3/11 Disclosure log Log requests made for discharge patient
record
1 hour Any request must be logged prior to
release.
3/18
ROI Requests for patient records made from a
3rd party, such as an attorney, or family
member-current and discharged
5 hours These requests must provide all
accurate info; if anything is wrong,
such as DOB or spelling of name,
request is denied. These requests
must be reviewed by RM, Admin,
and lawyer prior to release
3/18
ROI ROI Disclosure log-mult logs for facility,
HIPAA
1 hour This log is more detailed since it is a
3rd party requesting info that has
nothing to do with continuum of
care
3/22
Medical Record Thinning current patients’ charts 6 hours SNF has long-term patients; records
get thick and messy-very hard to
manage. Thinning removes older
info and leaves the current
orders/labs for the physicians.
3/29
Management
Meeting
QAPI, Quality Assurance and Performance
Improvement
6 hours This provides information from all
depts to improve performance
4/5 Medical
Records
Thinned Unit 2 records 6 hours
Audit Auditing closed charts 6 hours This is done within 30 days to make

15. 4/7 sure all forms are signed and all
information is accurate
4/12
Medical
Records
Pre-Authorization prior to admission-
request is made to admit patient; confirm
medical insurance and coverage
6 hours This is necessary so the facility
knows if the patient has coverage to
receive treatment, or if it will be
billed. Info is provided to patient
prior to admission, so if out of
pockets fees will incur, that patient
is not shocked.
4/15 Audit Quarterly Audits-performed each quarter
using both paper and electronic record for
current patients
6 hours This is performed to confirm all
orders are current and signed and
all assessments have been
performed
4/18 Audit Admission Audits-performed on each new
admission within 3 days of admission,
then again at 7 days and lastly 22 days (I
performed audits on closed charts as well
just for practice).
6 hours Paper and electronic system is used;
this must be performed to confirm
paperwork and consent was signed
and admission assessments were
performed
4/19 HIT Read HIT Manual for SNF 6 hours Provided policies and procedures for
Health Info Technician in a Skilled
Nursing Facility
4/21 HIT Reviewed HIT Manual and said goodbye 2 hours I will enjoy my new career as a
RHIT

17. Final Analysis
My experience at Silver Lake Center brought my education to
life. Theresa is very knowledgeable as a RHIT. She has made
me continue my excitement as I begin my new journey in the
healthcare industry. I am looking forward to joining Theresa
as a fellow RHIT.
The practicum experience allowed me to explore areas that I
have been taught in the last few years. This was a wonderful
opportunity to make my decision on where I would like my
career to lead me.
Silver Lake Center and its staff welcomed me with open arms
and I have much appreciation and gratitude. I am thankful
to DeVry for this experience.

20. April 21,2016
Theresa Oliphant
Medical RecordsCoordinator
Silver LakeNursingCenter
905 Tower Road
Bristol,PA
215-785-3201
Dear Theresa,
Thank youfor the opportunitytocomplete mypracticumforDeVryUniversityatyourfacility. Iappreciate the time you
tookout of yourbusyschedule toteachme about the Medical RecordsfieldinaSkilledNursingFacility. Ilearnedalot
fromyou in the last eightweeks. Ithashelpedme tomake a decisionwhere Iwouldlike topursue mynewcareer.
Please thankeveryone atthe facilityfortheirkindnessandwelcomingme intoyourfacility. Also,pleaseextendmy
gratitude tothe Administratorforallowingthe opportunityforme tocomplete myDeVryPracticum. Ihighly
recommendyourfacilitytofuture DeVrystudents. Iamveryproud and thankful toaddmy time at yourfacilitytomy
resume. Youhave givenme a great start intoHealthInformationTechnology.
Warmregards,
ShirleeScott
Shirlee Scott
DeVry Univeristy
609-724-8139
shirlelinke@yahoo.com