Essay Hybrid Health Record

1063 Words5 Pages
Running head: Hybrid Health Record
Hybrid Health Record
Ryan Engle 250129
Western Governor’s University

Management of health records is becoming increasingly complex. I will discuss the management of “Hybrid” health records, including legal issues. Additionally, I will evaluate a sample record policy for compliance with Washington State Administrative Code, Medicare Conditions of Participation, and Health Insurance Portability and Accountability act.

Hybrid Health Record
Electronic Health Records (EHR) transition from paper to electronic has necessitated a “hybrid” environment. The combination of paper, EHR, and document imaging (scanning) is causing challenges for Health Information Managers (HIM). Paper forms are
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Ancillary reports follow below subheadings. Physicians and nurses create paper charts, and that chart, when patient is discharged, is scanned into the EHR by an HIM. That data then becomes part of the legal document.
A legal medical record is described as residing wherever the document is born. When information is created in the form of an electronic database, which is the legal record. The EHR must be considered a document that can be subpoenaed for legal proceedings. Signatures, whether electronic or paper, must be documented in a master list that follows the chart at all times. The master signature list ensures that anyone that accessed the record, added or deleted information, and had direct care for the patient is appropriately documented.
When a Request for Information (ROI) is generated, a hybrid EHR becomes a good choice. The hybrid record, when imaging is used, allows for complete releases by the HIM without having to data mine the paper records. This increases productivity in the HIM by decreasing the time to find and copy data, and decreased the amount of paper required when the ROI can be fulfilled with electronic data transfer instead of paper being sent.
The “Willow Bend Record Policy” was established to establish guidelines for retention, storage, and destruction of health information. I will be evaluating this policy/procedure for compliance with Washington State Administrative Code (WAC) and the Revised Code of Washington (RCW),
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