1. First, I feel that the “cut and paste” method is a common problem that’s been raising by physicians. Since, the implementation of the EHR physicians want to cut ways on completing the documentation for patients by the use of this method. With that being said, physicians have found it easy to copy information…
Every long term care facility should maintain a master patient index (MPI) and admission and discharge register. The computer-based patient record system is supported by the organization-wide master patient index or other resident identification mediation service that ensures accurate and timely resident identification. The master patient index (MPI) is a valuable reference for basic demographic information and resident activity (i.e. admission and discharge dates) within one source. It is used to identify that a resident had…
Cheryl Fahrenholz throughout chapter 3 discusses various laws and acts that govern electronic health records and the principal functions that they provide. I picked five of these terms that I believe are the most important. Case management, Credentialing, informed consent, health record and performance improvement. Case-management is one of the most vital parts of any clinical faciality as it is through these individuals that the goals and livelihood of the patient are heard and responded to with corrective measures. The book describes this as an “ongoing review of clinical care conducted” safeguarding the patient against any treatment that is not in their best care (Fahrenholz, page 78 chapter 3).…
Maintenance of complete and accurate medical records for each patient as described in RC.01.01.01. This standard was also identified by JACHO as top compliance issue for the industry.…
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 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.…
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.…
Until the second part of the last century, all medical records were on paper. This system worked fine in an age of family doctors making house calls and patients never travelling far from their local hospital. Our modern society has changed and our healthcare record management has changed as well. Computerized record management (CRM) and Electronic Medical Records (EMR) are poised to increase the quality of healthcare. According to the US Department of Health and Human Services, there are numerous ways that CRM’s are improving quality of patient care. Their web site lists problems with paper records. These include, illegible handwriting, multiple healthcare providers for one patient not communicating, and increased amounts of medical and new drug information. “Patients with chronic diseases such as diabetes or congestive heart failure often have to monitor their blood glucose level, weight, blood pressure, and medication regimens in their homes” (AHRQ, 2012). CMR will allow health care providers to track any abnormal values recorded from patient’s home, eliminating the need to wait until the next appointment which may be a month away. With CMR, patients will be able to go to different specialists who can all plug in to the same medical record. Also, the medical record will follow the patient if he is travelling and needs to receive care far from his primary care provider. The switch to computer records will eliminate time trying to decipher a physician’s handwriting. EMR’s will also be updated continuously with updated medical and drug information. This resource will allow the healthcare provider to keep up to date on all the latest research which will increase quality of care as well. Another aspect of increased quality of care is the patient id band being linked to the electronic record. “The system of linking hospital ID bracelets to patients' EHRs has curbed medication errors” (iHealthbeat.org, 2012).…
The first goal listed by the Joint Commission (2013) includes improving the accuracy of resident identification. This primary goals focuses on helping to identifying a resident by using two specific identifiers. These identifiers are what help identify patients who are being treated with services and when given care (Joint Commission, 2013). Joint Commission’s safety goals confirm that wrong-resident mistakes can happen all stages of patient diagnosis and treatment.” For this reason, it is even more important to be able to get the proper identification to avoid such errors. The first goal in place was specifically set to identify the resident as the person who would be receiving care and to verify the service that the patient would be receiving at the same time. The Joint Commission (2013) allows for a residents name, identification number, and date of birth, telephone number or other person-specific identifiers to be acceptable.…
Electronic medical records act as an important factor in falling medical errors and increasing patient satisfaction. Electronic medical records keep a patient’s whole medical history. Physicians are capable to retrieve patient’s data at the click of a mouse. Data is accessible in real time, clinical imageries are freely accessible and a patient’s prescription description can be acquired at a more extemporaneous speed. Electronic medical records structures are top of the line software collections that cost thousands of dollars to carry out and sustain, but are worth every cent. To have medical records freely accessible to protect a life is invaluable. Electronic medical records are an advantage to patients. Margaret Richards states in her research that in the year 2000, there were an estimated 44,000 to 98,000 Americans who perished due to medical errors was reported by the Institute of Medicine (Richards, 2009). Possessing the capability to retriever patients’ records electronically has trimmed down hand writing mistakes, prescription mistakes and diagnosis…
“The electronic health record (EHR) is an evolving concept defined as a longitudinal collection of electronic health information about individual patients and populations. Primarily, it will be a mechanism for integrating health care information currently collected in both paper and electronic medical records (EMR) for the purpose of improving quality of care”. (p. 1).…
No matter how hard a person tries, no records will ever be 100 percent safe (Thede, 2010). The United States technology is ever changing and as the U.S. progresses hopefully the security will become more efficient. The dark era is coming to end because there was no evidence of safeguarding patient records. Moreover, paper records were causing a significant increase with health insurance payouts. Compared to other countries, the U.S. is lagging behind in the health care system. It’s hard to believe that once a powerful country could lag behind a healthcare system that Americans utilize every day. Privacy is up most importance, but in order for continuity of care to be equal across all health care providers is even more important than safeguarding a particular diagnosis that one might be ashamed of having.…