A. Develop an introduction (suggested length of 4-6 pages) for your capstone in which you do the following: 1. Describe your chosen topic within the field of HIM. The topic is Challenges in Clinical Documentation Improvement (CDI). Just elaborate and use any sources you may have or find to support the answer to this question. 2. Explain why you chose the topic. I chose this topic because I would like to become an expert in clinical documentation improvement (CDI) and help overcome the challenges in this field. Just elaborate and use any sources you may have or find. 3. Explain why you chose your research methodology. Use meta-analysis as choice for research methodology. This research method is also appropriate because of the literature review that needs to be included in this paper. Elaborate why this research method is effective for this capstone report and use sources you may have or find. 4. Discuss why the topic is important to the field of HIM. Discuss why clinical documentation improvement (CDI) and its challenges are important to the field of health information management (HIM). Elaborate and use any sources you may have or find. B. Explain the problem (suggested length of 35 pages) within the field of HIM your project will address by doing the following: Note: You may choose to refer to your sources to support your explanations. 1. Explain the problem related to your selected topic. Explain the problems and challenges related to clinical documentation improvement (CDI). Use any sources you may have or find to support the answer to this question 2. Describe background information about the problem. Describe the background information about the problems and challenges in clinical documentation improvement (CDI). Use any sources you may have or find to support the answer to this question. As you describe the background information (history, legislation, other ideas that show how this topic evolved) discuss how it is relevant to HIM and support your ideas with outside sources. 3. Discuss possible causes of the problem. Discuss possible causes of these problems and challenges. Use any sources you may have or find to support the answer to this question. 4. Explain why an examination of this problem is important to the field of HIM. Explain why an examination of the problems related to clinical documentation improvement (CDI) is important to the field of health information management (HIM). Use any sources you may have or find to support the answer to this question. C. Create a literature review by doing the following: 1. Summarize 1015 professional sources relevant to the topic challenges in clinical documentation improvement (CDI). Summarize each one of the 10 15 professional sources that you used to support why they are relevant to the chosen topic challenges in clinical documentation improvement (CDI). 2. Explain how each of the professional sources applies to the topic being investigated. Explain how each source (itemize 10 15 sources and the explanation on each one) applies to the challenges in clinical documentation improvement (CDI) topic. Below is 1 source and an example (unrelated to this paper) of how to answer questions C1 and C2. 10-15 sources and their summary of relevance to the topic and how these 10-15 sources apply to the topic challenges in clinical documentation improvement (CDI). Hodges, Rita. (2019). How and Why to Preserve Health Records during Litigation. Health information management (HIM) professionals have a duty to preserve information and to retain health information in accordance with regulatory requirements. But there is a distinction between retention and preservation. This article explains the legal differences and what questions the HIM professional needs to ask, in order to determine if information will need to be preserved in the event of litigation. The article covers four important points: the duty to preserve data, when to preserve information, determining what data to preserve, and three things to consider with preservation. Organizations create records for several reasons: business, medical, billing, and regulatory reasons. The question of when to preserve information is usually answered by an attorney, but it helps to be aware of what is usually a trigger event that alerts the HIM professional to preserve specific health information. If the organization is being served with a summons and complaint, or a subpoena, these would be clear trigger events, but oftentimes the HIM professional needs to use their judgment and consult with an attorney if there is any concern that a record needs to be preserved. Lastly, there are questions that need to be answered before preserving information, such as time periods of concern, the electronically stored information (ESI) that needs preservation, identifying the custodian of the specific ESI to preserve, and how decision-makers should answer scope questions. Scope is defined by what the party in the legal dispute is requesting and what the court will approve. This article was informative to my Capstone in the way it explained the difference between record retention and preservation, and the importance of HIM professionals knowing when legal issues arise, to work closely with attorneys. Even though the attorney will provide guidance, the HIIM professional has a duty to understand legal issues that may arise and follow legal guidelines in record preservation to best support their organization. You can see the 1 source on top, followed by a summary, (C1) and the last paragraph is your opinion what did you think of the article and how does it apply to your topic? (C2) You would use this format for displaying your C1 and C2 answers and summary of each source (10-15 sources needed). 3. Explain how all 10-15 sources used collectively support the chosen topic challenges in clinical documentation improvement (CDI).
