Health Information Management At Abc Hospital Essay

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

1. Fill in the table below with the results from the monosaccharide test experiment, and your conclusions based on those results.

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

Explanation: According to both HIPAA and ARRA regulations, healthcare organizations compels to allow all reasonable efforts to limit the disclosure of information to the minimum necessary data to accomplish the purpose of the request (McWay, 2010). Based on the information provided, the request for PHI fails to specify the date of validity of the release of PHI. According to the HIPAA privacy rule, a request for the release of PHI is invalid if the request meets the following specifications (1) expiration date not specified that is related to purpose of disclosure, or the date on the request for information has elapse, (2) If the authorization request have been revoked, (3) failure to clearly state the intended purpose of release of information, (4) failure to provide signature and date of authorizing the disclosure of information ( or failure to provide specification of the representative’s authority to act on behalf of the patients), and (5) failure to specify the entity disclosing and the recipient entity (Department of Health & Human Services, 2004). There

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

9. What measures in terms of physical storage are taken to ensure the privacy of the medical record?

There are many challenges associated with HHR. For example, there must be additional instructions to find the storage locations of patients’ health information. The instructions must show whether the documents are in electronic, paper, or scanned format. An additional process to link all of documentation formats needs to be deployed so that patients’ data can be collected and saved accurately. Not all the time those extra helps are available. Therefore, composing and organizing a completed HHR take a significant amount of time for health information management (HIM) professionals to gather all paper records and retrieve digital documents. The functions of HIM professionals encounter many challenges when working with HHR. The privacy and security policies for different types of records must be fully reinforced. Moreover, the updated data for each HHR have to be kept in detail for accuracy of information and easy accessing. In case of disclosing information requests, HIM professionals face a big burden of locating and verifying the information that is needed to fulfill the reasonable demand while limiting the release of information to the minimum. HIM professionals sometimes have to search through multiple systems to find the requested documents. According to Dimick, another disadvantage of the HHR system is when healthcare organizations participate in quality

Any patient that is seen by a physician within the United States is to be protected by the “Health Insurance Portability and Accountability Act” or HIPAA, which was passed into law in 1996 (Jani, 2009). All health care facilities dealing with any protected health information (PHI) are to ensure that all physical/electronic processes are safeguarded from any third party entity or unauthorized personnel according to HIPAA. All health care data to include any medical insurance

Joining the American Health Information Management Association (AHIMA) benefits individuals and distinguishes them apart from others. AHIMA labels individual’s as competent, knowledgeable and committed to the association through quality healthcare delivery and quality information.

Privacy policies can be particularly hard for an HIE to deal with .There are efforts such as the government's Connect project that provide

Many people are not aware of what professionals are responsible for in the fields of Management Information Systems and Health Care Information Systems or what well-paying jobs are available in those fields. Some people know a small of information about them but do nor do they understand why someone would want to major in these fields. This information obtained research of these fields will help the reader become more familiar help you become more familiar with what they are, what they do, the career choices they can provide, and how these fields is very dominate in today’s job market.

The department of Health and Human Services protects and guides the health and well being of individuals here in America (Thacker, 2014). They fulfill these duties providing Americans with adequate and efficient health and human services and monitoring services designed to increase the efficiency of care in the health system (Thacker, 2014). One of the services being monitored by the department of Health and Human Services is the electronic health record system, which carries private and vital information of patient’s health record enabling all eligible participating health workers access to these records (Thacker, 2014). A breach of the protective health information of patients in a health organization creates chaos as these are against the health insurance portability and accountability (HIPAA) law (Thacker, 2014). Hence, measure will have to be put in place to determine what caused the breach and how to rectify it to ensure the breach never happens again (Thacker, 2014).

Services are provided by highly qualified, cooperating with each other, mutually respectful and stable staff,