HIM 200 Journal

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Southern New Hampshire University *

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200

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Health Science

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Apr 3, 2024

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docx

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5

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Page 1 HIM- 200 – Journal Southern New Hampshire University Michelle Abbt Sunni Borghi March 16, 2024
2 Health Records: There are different types of medical records, paper, electronic, and hybrid. Paper being one of the oldest types of medical records, using paper record, does take time in completing, which can also create room for errors by poor penmanship and the interpretation of one’s handwriting, and possibly data that has been lost or forgotten. Using paper records, can also help with downtime forms when in today’s society if we lose power or internet. Paper records, there is also the struggle of storage as well, according to the Texas State Administrative Code, “Maintenance of Records: A licensed physician shall maintain adequate medical records or a patient for a minimum of seven years from the anniversary date of the last treatment by the physician.” (Texas Public Health). Electronic Health Records (EHR) is better with time, money and can be better secures than having paper records, as there is less chance of losing the data in the event of water or fire damage. Having an electronic record, you are able to store the data with a secured software, that can save to the cloud and have a higher form of security from data breaches. Having a compatible software, you are able to trace logs to employees that have accessed or changed any patient information. Electronic Records (EHR) can also help with accuracy of the records as well as a legal aspect if needed. Hybrid record is the combination of both the electronic records and the paper records, where the paper records is scanned into the electronic record, which will create a computer report. The hybrid record is the documentation of patient information that is tracked and stored in
Page 3 different places and other formats. Being able to store the patient information in various formats, can also help with having aback-up if one fails. Data: Patient data is collected and entered into their record for health care providers, to have the proper treatment and diagnosis. Data that is collected for the patient’s chart would be like patients’ medication, vitals and test results, this data can be very helpful for the treating physician. Being able to collect the history, and notes from the provider, also helps with the proper billing codes for the insurance companies. Templates: There are different forms within a patient’s medical records: I. Patients’ demographics form, this form contains, patents name, date of birth (DOB), etc. which is the most important form within their chart. II. Patient’s accounts information: Progress notes, scheduling, etc. this sheet helps with billing, and to go back to see what the patent had been seen for previously. III. Medical history, the second most valuable form within the patient’s chart, this is where we find the patients, past treatments, allergies, past medial history, etc. this helps the physicians, to have a better understanding of the patient’s health. IV. Medication list: this will list the patients most current medication and past medication. Having this sheet will help the physician to determine what
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