Electronic Patient Health Records

III.   Implications: In this section of the training manual, you will use the provided sample electronic patient health records to present examples of common coding and documentation errors to the trainees, and discuss the larger implications of these errors.

A. Clinical Mapping:

  1. Examine the electronic patient health records. Determine and assess the errors in clinical mapping. Be sure to specify which classification systems are not linked correctly.

2.  Explain the larger implications of these clinical mapping errors. Consider the impact on the following:

a) Patient safety and adverse events

b) Diagnostic errors and risks

 c) Billing and insurance

 d) Future care of the patient

 e) Public health and epidemiology

 f) Organization and physician reputation and cost

3. Create examples of appropriate clinical mapping between classification systems to correct the errors identified above.