Hi Prof. Antoisnne,
It is imperative that the HIM professional establish data standards to ensure data quality and consistency. Establishing data standards would help to ensure patient safety, consistent delivery of health care services, plan coordination of care, and standardize healthcare reporting.
Essentially, data standards are needed to assess the quality and consistency of collected data. Organizations need HIM professionals to familiarize themselves with these standards to create an organizational standardized data dictionary, format electronic health records, and standardize the exchange of health information across the continuum for general data management and to ensure the integrity and reliability of gathered data. We need data standards and quality measures to verify the validity, reliability, completeness, and the timeliness of the data that is collected. Additionally, there needs to be standards that address how data is recorded to safeguard the consistency across multiple sources (ex. radiology, laboratory, patient and administration) in an organization. Importantly, data fields and their content need to be standardized, as well.
…show more content…
Therefore, standards development organizations (SDOs) address a variety of aspects for the formulation of health and safety standards that create rules, guidelines, best practices, test methods and specifications for obtaining and measuring data. For example, the American Society for Testing and Materials (ASTM) and Health Level Seven (HL7) target clinical data
Assignment – There are five common purposes for medical records. List each of these purposes and provide an example of each in healthcare. Having good medical records is very important, for the proper care of patients. “Medical records can be used to manage healthcare, track healthcare, provide clinical data, meet regulatory requirements, and document healthcare” (Allen, 2013, P. 57). Without the proper documentation there is no proof that it was ever done.
They should be hold accountable for any breach in protocols. • Present format for electronic documentation does not allow for comprehensive clinical documentation during follow-up visit. Efforts should be made to upgrade the electronic medical record system to the standard of that expected for a medical center and research institute. This is to allow for proper documentation according to the industrial standard, and easy retrieval of patient’s information for clinical research. There is a need to employ a clinical documentation improvement specialist (CDIS) in this
#1- Compare and contrast the clinical uses of a health record with the secondary purposes of a health record. The use of Health Records are used by both, clinicians and non-clinicians (secondary purposes). Reasons to why clinicians may use a patient records are for confidential data such as patient care (diagnosis and treatment), chronological documentation of clinical care, method of cross discipline education, research activities, public health monitoring and for quality improvement activities. In contrast, non-clinicians may use is for non-confidential informational data such as billing and reimbursement, verifying disabilities, and legal documentation of care.
The Chief Information Officer is responsible for generating statistical data and gathering meaningful use data on patients. The Health Information Management Specialist is involve with meaningful use data input. Describe the statistical reports generated by the health information department. Only meaningful use: Smoking, Lipid Entry, Diabetes, and PHI Log
HL7 sets standards for the health care computer systems to exchange information. These standards provide functional models and profiles the permit the constructs for the management of electronic health records. You want the EHR software to be easily adaptable and user-friendly. Assess Your EHR Needs: Identify high-priority needs and EHR features that may meet those needs.
The purpose of the HIPAA transactions and code set standards is to simplify the processes and decrease the costs associated with payment for health care services. The transactions and code set standards apply to patient-identifiable health information transmitted electronically. Physician practices will continue to be able to submit paper claims. When the regulations take effect in October 2002, standard formats and code sets will take the place of any payer-specific or location-specific formats or requirements. ICD-9-CM Volume 1 and 2: Diagnosis Coding - ICD-9-CM is used to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys.
While reviewing the posts for team one discussion this week it looks like they are all agreed that standardization would have a positive within the healthcare system. Collecting data and the exchanging of health information are essential in improving patient safety and quality care. Having standardized terminology will simplify the transference of data among providers and decrease misunderstandings. I feel that only a few individuals directly mentioned how big of an impact standardization will have on overall clinical workflow. Standardization will allow clinicians to dedicate more time to patient
D. Extra Credit: Describe requirements for the new Hazard Communication Standard. The new Hazard Communication Standard, will include Hazard classification that provides specific standards for classification of health and physical hazards, as well as classification of mixtures. Labels, chemical manufacturers and importers or suppliers or distributors will be required to provide a label that includes a harmonized signal word, pictogram, hazard statement for each hazard class and group, and precautionary statements. Safety Data Sheets, Will now have a specified 16-section format. Information and training, Employers are required to train workers by December 1, 2013 on the new labels elements and safety data sheets format to accelerate recognition and understanding.
To lay the groundwork for portability, this rule set standardized codes and formats for the interchange of medical data and for administrative purposes. HIPAA mandates two types of codes for the transfer of data. First and most importantly, uniform codes are needed to describe diseases and injuries, describe the causes of the diseases and injuries, and to describe the preventions and treatments used. Secondly, there are smaller sets of codes for many administrative purposes—for describing ethnicity, the type of facility or the type of unit where care was performed. As much as possible, the major codes have been chosen based on code sets that are already in use, known as "legacy
Practice Fusion Electronic Health Record (EHR) System MEA-131 Ms. Slade June 17, 2016 Sharon Liles Practice Fusion Electronic Health Record (EHR) System Technology and the evolution of Electronic Health Records is an improvement to the efficiency and the effectiveness of how healthcare providers record, communicate and process patient information. According to Practice Fusion, “since 2005, the focus of Practice Fusion is expanding the ability to aggregate clinical data and share it meaningfully, by helping to make healthcare better for everyone. To improve clinical decision, support to tracking Meaningful Use, and provide insight that deliver better, safer and more efficient
Each year, the goals are analyzed and if necessary, updated. The 2016 National Patient Safety Goals aim to: 1) Improve the accuracy of patient and resident identification; 2) Improve the effective communication of caregivers; 3) Improve the safety of medication use; 4) Improve the safety of clinical alarm systems; 5) Reduce the risk of health care associated infections; 6) Organize identification of safety risks evident in patient populations; and 7) Set universal protocol for preventing wrong site/procedure/person surgeries (TJC, 2016). These safety goals are mandated so that medical errors are reduced and patients are given the best quality care possible. Some of the steps nurses can take in association with these goals include: using at least two patient identifiers to ensure correct patient treatment and reduce patient misidentification; making timely reports of critical test and diagnostic results; maintaining accurate patient medication information, and labeling all medications and containers removed from original containers; quickly responding to medical equipment alarms, and maintaining their upkeep; following hand hygiene guidelines, and using evidence-based practices to prevent infections due to multi drug-resistant organisms, surgical sites, or indwelling catheters; identifying patients at risk for suicide; and ensuring that sites are correctly marked for surgery through marking the procedure site and undergoing a verification process (Cherry & Jacobs,
2.1 Device a strategy and criteria for measuring recent changes in Health and social care My organisation Royal United Hospital had breach policies and procedures related to respecting and involving users of the services, standard of care did not uphold the policy of safeguarding service users from abuse and monitoring the services on a regular basis and updating of DSU records. My duty to the organisations is to devise strategy and criteria to measure standards in the organisation to bring in line with National Standard 2008, a provider of health and social care providers must ensure that service users are given appropriate treatment, in line with regulation 20 of health and social care Act 2008. I will measure the standard of service offered by using two methods, quantitative and qualitative by gathering information from for customers, Stake holders, regulators, internal and external customers, I will also
Some possibilities include Evidence-Based Documentation, Multidisciplinary Collaboration, Patient Safety, Care Quality, Care Specialties, Time Efficiency, and so on. Some limitations of the MEDITECH
The healthcare industry generates a great amount of data every day, as a form of record keeping, patient care, compliance, and regulatory requirements. Just a decade ago, all this data was stored in the form of hard copy form, now it is rapidly transforming to digital data which is called EMR (Electronic Medical Record). The digitalization of the healthcare has not just reduced cost of care, but also improved quality of care due to the abundance data that organizations receive from the EMR to identify the flaws in their system. I work in the healthcare industry where improving quality of care is our primary goal. We use software called eCW , which is an integrated system.
Quality assurance of medical records following sure all rules and regulations were followed for Joint Commission Accreditation of Healthcare Organization (JCAHO) review. Processed, logged, copied, and properly mailed records and correspondence to patients and outside agencies. Organized administrative activities for 297-person organization. Independently performed assigned duties in accordance with regulatory guidance and accreditation guidelines, using discretion and judgment to make appropriate methodology. Provided advice and regulatory guidance, verbally and written to staff.