Brenda Johnson is one of two inpatient coders at Community Hospital. The coders generally experience poor interpersonal communication and there has been a long time feeling of distrust and lack of close knit relationships among the coding staff. Brenda, who is not married, becomes pregnant and experiences early complications. She is taken to the Community Hospital ER and admitted. Complications were caused by the presence of genital herpes and chlamydia.
Before her discharge from the hospital, Brenda contacts Shirley, director of the Health Information services. Brenda expressed her concern regarding having her records sequestered during her absence, so that her coworkers would not have access to her records. Shirley assured her that the staff are bound to their confidentiality statements and that her records would be handled in a professional manner. Brenda stated that she would prefer to process the record herself if it could be sequestered until her return to work.
Shirley agreed, as Brenda was to return back to work in a week. However, Brenda developed complications that resulted in additional hospitalization. Brenda was re hospitalized. Brenda contacted Shirley urging her to keep the records secure from the rest of the department. Brenda also indicated that the hospitalization could potentially last until the end of her pregnancy. Shirley pointed out to her that it would not be fiscally responsible to hold up billing and additional processing of the record until she returned.Brenda asked if it would be possible for her to code her previous admission while she was in the hospital and even code her present hospitalization immediately after discharge prior to being transported back home. Shirley explained that it would not be appropriate for Brenda to be coding her record while hospitalized and her current record might not be complete enough for coding immediately after her discharge.
Qu. 1. What internal and external forces impact this case?
Qu. 2. What are the legal issues addressed in this case?
Qu. 3. What are the ethical issues addressed in this case?
Qu. 4. How are the ethical issues in this case covered in the American Health Information Management Association Code of Ethics?
Qu. 5. Is Brenda’s request to have her records sequestered appropriate, considering her distrust of her coworkers and the delicate nature of her health status?
Qu. 6. What implications could there be if Shirley were to allow Brenda to code her own records while in-house and immediately after her discharge?
Qu. 7. If Brenda were allowed to code her own record while in-house, she would most likely utilize a code book, rather than an encoder, because she is restricted to her hospital bed. If she were to become injured from lifting the code book and/or chart, what are the liability considerations for the facility?
Qu. 8. Using the case method, evaluate possible actions that should be taken and determine the best option
