Carol Alborn HIM CORE Day 11 9/12/2011 Purpose and Function of the Health Record A health record is a virtual storage place that documents health care services from healthcare providers at various locations such as the DR.’s office, nursing homes and ambulatory service locations. It’s made up of data or facts from the patient and family members, and these healthcare services, which is analyzed for useful information. It is the HIM professional’s responsibility to take data from traditional practice forms and any Personal Health Record (PHR) or from any other sources, then enter data into the Electronic Health Record (EHR) system. Anything missing can alter the patients care. Its Primary purpose is to ensure quality patient care and managing the cost of that care.
Health care providers have an ethical obligation to instruct their patients about the accessible electronic PHR choices, tougher encryption prerequisites, and federally approved code of practice, such as Health Insurance Portability and Accountability Act (HIPAA) to certify the security of their records. The reason for this thesis is to recognize the concerns associated with electronic PHRs, hand-pick an
It helps to meet both quality and cost effective measures by patients. (Leatherman, 2013) United health care effectively communicates the performance results and feedback to the customers that provides the detailed process of decision making abilities. United Health care provides the important guidelines of preventing health issues at an initial stage which is important in healthy life style. It helps to make the patients healthy. United health group is committed to offer a wide range of health insurance plans and other benefits.
Addresses National Patient Safety Goals. Follows all rights of medication administration. Knowledgeable about medications, appropriate lab values, vitals, etc. with prompting. Not independent on po medication administration.
Unit HSC 038 Promote Good Practice in Handling Information in Health and Social Care Settings 1.1: Identify legislation and codes of practice that relate to handling information in health and social care. All information that is stored is subject to the Data Protection Act 1998. In Jersey legislation and codes of practice that relate to handling information are: • Data Protection (Jersey) Law 2005. This is based on principles to follow rather than legislation. A copy of this is available to the public on the States of Jersey website www.gov.je • The Caldicott Committee- report on the review on patient identifiable information Dec 1997.
They set standards of practice, handling information and maintaining confidentiality. Within my role I am bound by these professional codes of practice. The Caldicott Standards are protocols that have been nationally agreed on individual confidentiality and form health guidance principles. Within my role and organisation we apply these principles to actions relating to information. Other legal sources of information regarding handling information are stipulated through common law.
Electronic Medical records contain a range of data including, billing information, demographics, age and weight, medical histories, vital signs, medication, allergies, immunization, radiology images, and lab results. It is a complete patient record that allows streamlining and automation in the health care setting. Electronic medical Records increase safety through, evidence based decision support, outcomes in reporting, and in quality management. Electronic Medical Records have made a huge impact on the health care field. By moving patient records to computerized system it has improved efficiencies for patients, health
Work with a screening vendor that understands and monitors health care regulations and can provide updates to these regulations to support your organizational needs. Health care organizations must always consult with their legal team on these matters; however, an experienced screening provider can help increase awareness around evolving legislative and regulatory issues. • Comprehensive and Accurate Results To ensure optimal data quality and accuracy, the background screening information delivered to an organization should come from the best possible resource—the primary source. This means the data used in the background report was collected from the originating source of information. Understand how the data in the screening reports is collected and compiled.
This means strengthening the human resources, integration of potential data sources as well as use of the data within the country. Such systems ensure the production, analysis, dissemination and use of reliable, timely information on health determinants, health system performance, and health status. (www.cdc.gov) HIS has the potential to significantly increase the efficiency of the health sector by helping providers manage information. It could also improve the quality of health care and, ultimately, the outcomes of that care for patients. When used effectively, HIS can enable providers to deliver health care more efficiently.
Unit 4222-209 Handle information in health and social care Settings Outcome 1 Understand the need for secure handling of information in Health and social care settings 1. Identify the legislation that relates to the recording, storage and sharing of information in health and social care The right to confidentiality is guaranteed by the Data Protection Act 1998. The Data protection Act 1998 sets out eight principles which are in essence a code of good practice for processing personal data. The data must be • Fairly and lawfully processed • Processed for limited purposes • Adequate, relevant and not excessive • Accurate • Not kept for longer than necessary • Processed in accordance with the data subject’s rights • Kept secure • Not transferred to countries without adequate protection Your workplace policies and procedures will be based around those principles. The Human Rights Act 1998 details the right to a private life.