Chart Contraction Of A Medical Chart Analysis

In the event of releasing any patient information it is important to make sure that all of your T’s are crossed and your I’s are dotted before the transaction is complete. However, because specialized patient records, such as Mental health or substance abuse cases, contain not only strictly medical information, but also therapeutic mental and emotional information, the release of this type of information could cause some damage to the patient (McWay, 2010, p. 227). This is why the release of information concerning this type of patient records is different from that of a patient record without delicate information in it.

Discuss what is required to disclose patient information to family members, friends, and when ordered by courts or government

Jim Philips is the attorney for Karen Munstrom. Karen is filing suit against Howard Doe in a domestic dispute. Jim Philips sends Memorial Hospital an original authorization that is signed and dated by Karen Munstrom. The authorization, addressed to your hospital, includes the dates of the records requested. The authorization does not state the type or subject of the information to be disclosed. The records of Ms. Munstrom are related to a stay for alcohol rehabilitation.

Disclosure for direct patient care emphasizes the importance of limiting the exposure of health care information of a patient to only the one offering treatment. Although physicians are not required to receive their patient’s authorization, others healthcare workers, such as billers, coders, and front desk staff, are not allow to gain access to patient’s health information. In my opinion, this disclosure is essential to those whose careers are in the medical field. My mother is a registered nurse at the same hospital I was admitted to multiple of times for several unexpected emergencies. Although her coworkers shown concern, my personal information, lab results, and the treatments are confidential and only my mother and my physician are allow to see this private information. Several of years later, when I moved from New Jersey to Maryland, I felt comfortable having control of my health information by being asked to call my old physician to fax my health records to my new general physician. After calling, they also required my new physician to send a fax to them with my signature ensuring that my information is secured and only the new physician who is responsible for my care receives and reviews it. A

It is important for the both the patient and health care provider to understand what information is being protected, as to avoid any security breach. This protected information included any information in various medical records, patient conversations with all health care professionals about care and treatment, billing data, and a majority of other information regarding patient health. Any patient has the right to see and receive a copy of any health records, request correction be made to a variety of health-related information, control over who the medical records are shared with,

A patient records whether it is electronic, as a EHR or a paper record contains sensitive, personal, and private information about the patient and should not disclosed to any unauthorized individual, as well as used unwarrantedly. (Mir, May-June, 2011). Healthcare organizations, such as United General Hospital should have instructions for staff to follow in regards to handing and accessing patient records. In updating the management training manual for United General Hospital, it is required that all authorized staff abide the instructions while handling and accessing patient records. Upon handling and accessing patient records all required and authorized staff based on “a need to see basics” and for medical treatment and financial purposes

Electronic charting has become the norm in the medical world and if a facility is not currently charting their patients’ health care data on a computer they are extremely behind in the current trends. Since charting on a computer has become the norm for medical facilities many different charting systems have been developed for health care providers to use to chart their patients’ health care information. Learning how to navigate these systems can be challenging, especially if a health care provider works at several different medical facilities and they all use a different electronic charting program. Some health care professionals have advised that all medical facilities turn to only one software program. They argue that this would make it easier for all health care professionals because they would only have to learn one system to chart on their patients. This universal electronic chart would follow the patient so that it

A medical record, whether in a physical record or an electronic form is a legal document that should “reflect an accurate chronology of events” (Brous, E., 01 Feb., 2009, para. 2). Without exception, every entry must be dated with a year, time recorded with either am, pm, or in military time, and the medical record should be signed with a last name and the doctor’s status. Furthermore, the medical record should read like a book; as well as paint a picture of the patient so that others who reach the chart will know what the doctor saw and did to the patient. Doctors that document about the patient and what the

A medical record has many essential roles within any health care organization; these records contain a plethora of medical information for the patient. Medical records are required to contain correct and precise information such as patient demographics (address, phone number, and age), any consent and authorization forms that the patient signed for treatment, family and patient medical history, and any diagnosis that is made using the patient’s medical history and their current health complaints. All information that pertains to the patient must be included in their record. Along with the patient information the medical record is required to contain all doctor orders, nurse notes, progress reports, diagnostic reports, fluid intake and output amounts and frequency, pain management, and all discharge planning and patient education (Pozgar 2007). It is beyond important that all health

The EHR provides easy, accessible, complete medical information, providing that the information is entered correctly. Often, information that the patient cannot remember, for instance home medications or allergies, are saved within the EHR and can be reviewed with the patient, assisting the patient to remember the medication names; therefore, assisting the nurses with appropriate medication administration decisions. Another advantage of the EHR is the ability to save medical interactions, and then add upon the list of medical diagnoses as care is delivered. Many times, patients do not remember the details of treatment received in the past, such as diagnosis, but they can remember once the medical term is mentioned. Having information to assist the patient with remembering past medical conditions will improve care delivery and increase patient safety by enhancing the nurse’s knowledge of past medical problems.

Slide 11: Human errors, such as medication errors or allergy errors, are minimized with alerts on the electronic health record. The electronic health record has shown to reduce the number of missing charts (82%), and improves data accessibility to patient records and documentation remotely (75%) (Narisi, 2013). By eliminating paper charting, the EHR makes all patient’s data and information available at all times to all physicians. The EHR improves patient care delivery by reducing the error of hand-written orders and allows for other physicians to access the order. This is great for when the doctor orders a medication to start stat, and puts the order into the EHR, so the nurse can start the medication right away (Palma, 2013).

Iowa Department of Inspection and Appeals require that all medical information obtained in connection with the reasonable accommodation will be stored and kept confidential (Smith, 2014). Hence, medical information must be obtained with a request for reasonable accommodation will be stored and maintained in files separate from the individual’s personnel file in accordance with medical government employee. Describing the mission, policy issues, and methods for staying up to date on styles and practices are addressed, by focusing more on intelligence file guidelines and ensuring accountability of the intelligence function.

It is imperative that the patient medical record is complete to ensure accuracy and reduce errors. The key issue with maintaining patient privacy is that there are multiple people involved in treating them, which allows more opportunity for health information to be accessible whether intentionally or unintentionally. The Health Insurance Portability and Accountability Act is in place to reinforce the need to protect the patient’s privacy. The overlapping responsibilities of the team assure that the record contains pertinent information and is only handled by essential personnel, this safeguards the integrity of the medical data to make sure that they are in line with the HIPAA

Employees in a healthcare facility or related are required to be trained in the proper handling of the patient’s medical information. According to the U.S. Department of Health & Human Services Office for Civil Rights “Providers and health insurers who are required

“an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (CMS)”