Name of facility
Accredited by JCAHO or AOA: Teaching or non-teaching facility?
Licensed bed capacity
Annual admissions and outpatient visits (most recent year)
Number of active medical staff members
Number of full-time equivalents in Health Information Management Department
Describe the different areas of the department. List the department's hours of operation.
Describe the functions performed by each unit, section or division of the department (in small departments, list the functions performed by each position).
Is any portion of the department unionized?
Does the department have specific work standards, such as minimum accuracy/speed requirements for any positions? What are they?
Does the department handle medical transcription? What type of equipment is used? Is it outsourced or done in-house? If outsourced, how is the company paid? By the line, page, etc.?
What coding/abstracting systems are used?
How current is the department in responding to release of information requests?
Describe the role of the department in the institution's "performance improvement", "quality assurance" and "utilization management" efforts. How do they participate? Who is involved?
Are there components of an Electronic Health Record? If so describe the extent of the electronic health record. What software is used? Is it a hybrid?
Is there a paper medical record filing system? If so, does a true unit record exist? When are records microfilmed or scanned?
Is the facility connected to a Health Information Exchange? If so, how is the data exchanged? Who is responsible for this managing this function?
Are quality/quantity checks performed for any of the procedures you observed? Who does them? How do they do them?
Describe any computer applications either within the department or impacting the department. What is its purpose?
How are the employees and supervisors evaluated? How frequently?
How are employees disciplined, when such action becomes necessary?
Do any work backlogs exist? Why do you think they occur?
How did the department employees react to your presence?
How would you characterize the relationship between the department and its clients? Positive or negative and why?
What is your overall perception of the HIM Department and the facility?