Operative Report Time Re-Design Project

I have worked in healthcare for 5 years and in the Health Information Management Department for 3.5 of those years. In those 3.5 years, I did not experience or have in depth knowledge all of the different aspects of HIMS. This internship has allowed me to learn all of the different aspects and jobs. I shadowed many people in areas such as scanning, analysis, and IT. If I had not already worked in HIMS, I would have been surprised at all of the different areas of HIMS and how much support they give.The first project was the Operative Report Time Re-Design project. The project involved analyzing operative records in Epic and comparing elements against internal policy requirements. Tracked noncompliant operative records in an Excel spreadsheet listing details including out-of-room date/times, documentation entered, and staff entering the documentation. This Excel spreadsheet was sent to HIMS leaders and to our Epic OpTime team to justify the need for re-design of operative templates.

The second project was the ProcDoc project. There was a specific department at one of the locations where their procedures were being performed by a Fellow but the fellow was not listed on the procedure note. These notes were documented with the ProcDoc template. The purpose of this review was to see how many of the procedures done from June had the fellow listed within the procedure note. They also wanted to make sure other elements like estimate blood loss, specimens, Pre-Op diagnosis, and post-op diagnosis were being documented as well.