Fourth grade student Jasmine Keller was informally assessed in 2009 and found to be reading at a level between first and second grade. Her vocabulary is stronger and at grade level with 85% accuracy. Evidence also from 2009 indicates Jasmine is able to produce ideas and sequence meaningful supporting details. Additionally, her math computation is weak and a pre-assessment found her scoring 32 facts correct out of 102. Her progress is inconsistent and unreliable, and many of her teachers have voiced concern regarding Jasmine’s weak short term memory obstructing her learning. Based on evidence from her assessments and classroom work samples,…
3. What measures can a hospital take to improve data integrity in their EHR while still achieving their goal of streamlining the documentation process?…
There are several roles within the health information management (HIM) profession. A HIM professional gathers, preserves, evaluates and guard’s personal health information within many different health care settings. One of the most important duties in regards to a HIM professional is ensuring compliance and upholding the current regulations in the health care industry. This paper will take a closer look at the specifics of what a HIM professional does to ensure compliance as well as the importance of education and certifications that many employers are now requiring for potential candidates in the HIM field.…
Health care information systems are a collection of data and information unique to health care. This information includes starting with an information structure that collects both administrative and clinical patient data, compiles the information, makes information available for up-to-date patient care all the way through the reimbursement process. These systems also aggregate data for reporting to measure outcomes. A description of different types of patient information and the key elements associated with the capture of health care data will be discussed.…
Health information management is highly involved with the Accreditation process for the Joint Commission. Accreditation is an indicator that the facility provides high quality care. The Joint Commission has set standards for health record documentation. The record is essential because it contains all information from the time the patient enters the hospital to the time they are discharged. This is a way physicians and health care providers communicate and is important and for continuity of care. One of HIM goal is to improve patient safety and health care quality, which is a standard and expectation for the Joint Commission. Since HIM works hand and hand with physicians and health care providers HIM is responsible for conducting audits on…
AHIMA e-HIM Workgroup on Assessing and Improving Healthcare Data Quality in the EHR. “Assessing and Improving EHR…
The effectiveness of databases is based on the fact that from one single, inclusive database much information regarding a range of organizational principles can be obtained. In the health care industry database systems allows information to be shared and available to different users; it can provide an accurate, consistent, and up-to-date information about a patient’s condition and treatment, as well as provide a security measure so that the information is only viewable to those who should see it.…
Electronic health records (EHR) are often confused in terminology with electronic medical records and the two are vastly different with only a few similarities. Electronic medical records are the culmination of medical information of patients in one office. Electronic health records are designed to follow the patient wherever they receive care to build a complete history of care, treatment, and diagnoses to allow accurate care. EHR’s design is to be shared with any provider, health care system or organization, and ancillary provider to easily share the patient’s health history. This culmination of information follows the patient to any facility in town, in the state, or in the country to provide the most effective history on the…
Data quality is vital to patient safety. If information is inaccurately recorded it can lead to all sorts of complications. “Patient safety is affected by inadequate information, illegible entries, misinterpretations, and insufficient interoperability.” (Wager, Lee, & Glaser, 2009, p.…
An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient encounters. It also allows for the automation and streamlining of the workflow on health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting. There are many functions associated with patient health records. Not only is the record used to document patient care, but the record is also used for financial, legal information, research, and quality improvement purposes. The integration of technology and health care will enable health professionals to provide more effective quality care.…
The AHIMA was founded in 1928 by the American college of Surgeons when they first established the Association of record Librarians of North America. The AHIMA was created to improve health record quality, and the effective management of health data, so that healthcare providers could deliver quality care to the public. Throughout the decades there has been several name changes. In 1938 the Association changed its name to the American Association of Medical Record Librarians, then again in 1970 when it became the American Medical Record Association. The last name change came in 1991 to what all HIM professionals have come to know as the American Health Information Association. These name changes come as a reflection to the Associations process for moving forward with its knowledge and technology. The AHIMA mission for making this possible, is by transforming health data. The AHIMA is committed to developing HIM leaders throughout the profession. Recognizing that HIM professionals are health industry experts. AHIMA is advancing new software and technology, and the HIM professional are benefiting from this. The association is also encouraging the public to get involved in their own personal health records. The AHIMA forefathers paved the way, so that I as a soon to be emerging HIM professional, may have the right skills and tools needed to be successful in the career that they worked so…
Consumers today have the ability to access information related to their daily lives or even information related to events happening on the opposite side of the world. However, if this same consumer needed access to his or her personal health information, the ability of the patient or their health care provider to obtain the information would be limited. (Medows) Personal health information is not used to its full potential to support effective and efficient care due to fragmented information creation and storage. Our fast-paced always on the go society calls for a change to this state of isolated, fragmented health information. Whether it be a patient relocated due to a natural disaster or being able to identify a patient who was prescribed a recalled drug, having access to health information no matter where the patient may be is necessary. (Vest and Gamm, 2010) Making health information technology (HIT) will not only enable healthcare consumers access to their own medical history but also ensure that healthcare providers have timely access to medical records, improve the ease and safety of e-prescribing, improve payer reimbursement, and provide the information needed for population based health planning. (Medows) Policy makers, researchers, industry groups, and health care professionals agree that health information exchange (HIE) is the much needed solution. (Vest and Gamm, 2010)…
Wager, K. A., Lee, F. W., & Glaser, J. P. (2009). Health care information systems: A…
The electronic health record also known as the EHR, has transformed the world of health care and documentation as we know it. An electronic health record is a “ computer-based data warehouse or repository of information regarding the health status of a client, which is replacing the former paper-based medical record; it is the systematic documentation of a client’s health status and health care in a secured digital format , meaning that is can be processed, stored, transmitted, and accessed by authorized interdisciplinary professionals for the purpose of supporting efficient, high-quality health care across the client’s…
Healthcare database systems are critical in health care. Databases are used frequently in healthcare. There are different types of databases. This paper will define health care database systems and describe how databases are used across the health care industry. It will also explain the different database architectures including the relational architecture and describe the needs of database users across the health care continuum. A database is any collection of data organized for storage, accessibility, and retrieval. A healthcare database serves to replace the paper documents, file folders, and filing cabinets of old. This makes data more convenient and immediate.…