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
Establishing standards for vocabularies promote data quality within health information systems. Scholarly works support this principle within the Health Information Management profession. The following articles support data quality, standardization, and interoperability as critical components of health information management and exchange. The goal of true exchange will include data sharing of critical information across the care continuum, often across disparate systems.
An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The
Healthcare has evolved over past decades and continues to remain an issue of concern for individuals everywhere. Effectively managing data is important to improving the performance in the health care system. Accumulating, evaluating, deciphering and acting on data for particular performance measures allow health professionals to identify shortcomings and make the necessary adjustment, and track the outcome.
To assess the quality of health care it is providing Quality healthcare depends on the availability of condition data. Poor documentation, imprecise statistics, and insufficient communication can result in errors and adverse incidents. Inaccurate data intimidate patient well-being and can lead to expand costs, inefficiencies, and poor presentation. Further, mistaken or incomplete data also discourage health information exchange and obstruct clinical research, production development, and quality initiatives. The impact of poor data on care is only increased by the implementation. A consequential electronic health record ameliorates the capability for healthcare providers to enact evidence-based comprehension management and decision making for
Electronic Health Record (EHR) is 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 (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in
Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,
In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American
An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient
AHIMA recognizes that superior quality health care and clinical data are critical resources needed for effective healthcare, and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. This group is concerned about the effective management of health information from all sources and its application in all forms of healthcare and wellness preservation. Health issues, disease, and care quality also transcend across national borders. AHIMA’s professional interest is in the application of best health information management practices when and wherever they are needed. (The American Health Information Management Association, 2010).
The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.
As of 2011, approximately 54% of physicians had adopted an electronic health record system (Jamoom, Beatty, Bercovitz, et al., 2012). Electronic health records are a digital version of a patient’s medical chart that are protected and quick to access. They often contain important patient information such as medical history, allergies, diagnoses, medications, test results, and treatment histories. Electronic health records can affect the quality and efficiency of patient care, the timeliness of accessing patient information, and the likelihood of errors.
This article addresses the importance of collecting accurate and complete coded data along with using uniform coding standards. The collection of accurate and complete coded data is essential because it influences policy-making, public reporting, research, reimbursement, and healthcare delivery. Likewise, use of the uniform coding standards are crucial because they affect the quality of healthcare delivery by reducing administrative costs, and improving data quality and integrity.
Once data is collected it can be used by numerous health care providers and decision makers to monitor the health and needs of individuals and populations, as well as contribute to the analysis of the health system. Users including hospitals, health care practitioners, government, professional associations, researchers, media, students, and the general public. Having the correct and up-to-date coded data is critical, not only for the delivery of high-quality clinical care, but also for continuing health care, maintaining health care at an optimum level, for clinical and health service research, and planning and management of