UHM1 Task 3 Health records

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Western Governors University *

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MISC

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Health Science

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Dec 6, 2023

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docx

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5

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Running head: UHM1 TASK 3: HEALTH RECORDS 1 UHM1 Task 3: Health Records Jessica Blair WGU
UHM1 TASK 3: HEALTH RECORDS 2 UHM1 Task 3: Health Records A. Compare the characteristics of paper, hybrid, and fully electronic health records: Paper records have a lower upfront cost for a facility; however, the drawbacks include being less efficient as it takes longer to retrieve information and it takes longer for labs and radiologists to receive doctor orders. It also takes longer to be able to retrieve results for scans. Even more importantly, the storage and disposal requirements are more physical. For example, since PHI must be unrecognizable, proper disposal includes shredding or burning. Electronic records are more costly than paper records and require more training but if the facility system has complete interoperability, then record retrieval would be easier. Physicians would be able to enter orders through computerized order entry. These digital documents need to have restricted access and remain HIPAA compliant when accessing and transferring information. A facility with hybrid records means the facility has both paper and electronic documents and they would need a process in place to ensure paper records are connected to the correct patient. Sometimes paper documents are uploaded to become an electronic document, but it is unable to be modified. To make any necessary changes in a hybrid format, it depends on whether the document is paper or electronic. For paper documents one adds an amendment and signs it. For electronic, one would use the feature in the practice management system used for amendments which also would include an electronic signature and the time. 1. Discuss issues that may affect the use of hybrid records for legal purposes: For hybrid records the facility must ensure that they have procedures in place for
UHM1 TASK 3: HEALTH RECORDS 3 storing and retrieving paper records as well as their electronic ones. Both would have separate rules for privacy simply because with paper documents there is not necessarily a security risk using technology unless it is scanned into the system. It would most likely be stored physically in a specified location that would need physical deterrents such as security cameras and key cards with approved access. Electronic records would need encryption and password access to PHI. Hybrid records also must have a way to find the source of every document and it must be signed by the physician. If any changes are made to either paper or electronic documents there must be a process in place for adding changes without deleting any original information (Johns, 2015). Because of a hybrid format using two different systems it can get tricky when a patient’s complete record is needed for legal action. It is more difficult to keep organized, and the facility must ensure that no piece of information was left out of the record- intentionally or otherwise. The integrity of the record can come into question if staff are not following proper procedures on adding changes. B. Evaluating the Cedar Bend Record Policy. 1. Describe whether the Cedar Bend record policy would comply with a chosen state’s regulations, including your reasoning: The Cedar Bend record policy would comply with North Carolina’s record retention policy. For the retention timelines Cedar Bend states to retain records for 10 years, diagnostic images for 5, and infant records for 10 years after they come of age. In NC the timeline is the same except minors’ records are also held for 10 years or 4 years after reaching 18
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