The Master Patient Index provides a comprehensive overview of a patient’s complete medical history in addition to treatment history. One of the most used software in healthcare facilities provides access to patient information related to accurate and current demographic information, and medical data on past and current patients from multiple departments. The MP1 allows the capability for a healthcare provider to narrow the list down to specifics in order to identify the specific facility which a patient receives care in addition the healthcare professionals which were involved in the care that was provided. With such vast and extensive programming software, errors are pertinent. Errors are often unintentional but can be time consuming and costly …show more content…
Rather than pulling an existing account to continue, the healthcare professional creates a new account and uses that. This poses a problem due to not continuing care. The new account does not contain the patient’s previous care, medication record, lab and test results or treatments and procedures. It’s as if the patient is starting with a blank slate and the existing information is not being utilized. Many times, this happens due to the search of incorrect information in the Master Patient Index. If a patient was assigned a new social security number, had a change of address, or married and took a new last name then finding an existing account would be difficult without diligence. To correct this error, a health information management professional would need to merge the two accounts. This typically involves verifying that the new account and the existing account are indeed the same person, updating the information that caused the error, and moving all of the information into the same account. These corrections may be done with an HIM professional, or could be outsourced to a third-party vendor whose sole responsibility is verifying correct Master Patient Index …show more content…
The term data quality refers to preserving the integrity of the data collection and application for the medical care and treatment of a patient. Well written, thorough, and concise documentation is mandatory in maintaining proper patient records. Patient documentation should include patient’s symptoms, complaints, history, treatment, physical assessments, medication history and other details such as date and time of visit, and proper signatures for the healthcare provider who is documenting the information. Quality data documentation aids in proper diagnosis and treatment plans which reduces the risk of liability for the provider and undue harm for the patient. Something as simple as summarizing a patients complaint without documenting the patients exact words and description of complain can delay a diagnosis due to higher level care personnel working with less information. Documentation does not just affect the care of the visit, improper documentation can hinder a patient’s care after discharge. If a patient requires a follow up for lab testing or medication effectiveness and it is not documented, the result of care will be unknown. Data quality is pertinent as a whole, but more so with certain patient groups or age
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
... basic information of the patient. Professional and precise language should be used when documenting. For the care plan, I have learned to correctly write a nursing diagnosis and writing interventions that are within nurses’ capability and suits the patient’s personal status. From now on, I will remember to distinguish medical diagnosis from nursing diagnosis. For each diagnosis, I will write about the patient’s (potential) response to the health problem and state why this might be the concern.
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
Errors caused by system problems can be prevented by working with your vendor to reset user preferences as needed. In order to preserve data quality and protect patient safety, it is very important that all medical records contain correct information for the safety and treatment of the patient. It is very important to note any cha...
Learning Experience Journal Entry – Director of Health Information Management and the Supervisor of Medical Records Coder
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.
In the health care industry, gathering information in order to find the best diagnosis route or even determine patient satisfaction is necessary. This is complete by conducting a survey and collecting data. When the information is complete, we then have statistical information used to make administrative decision within the healthcare field. The collection of meaningful statistics is an important function of any hospital or clinic.
Introduction The Clinical Documentation Improvement (CDI) program has continued to provide a pathway for improving Physician’s clinical documentation. This requires a collaborative effort from the Health Information Management (HIM) professionals to assist the Physicians in maintaining a sound health record to enhance clinical clarity. From the onset, the use of CDI program has continued to thrive in all healthcare settings across the United States (especially in the hospitals) as a holistic approach to promote effective data quality reporting. Expanding the CDI initiative into ambulatory and outpatient settings have become an increased focus for the CDI specialist to ensure a smooth data reporting. Beyond these measures, many private
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
Both data integrity and data quality are organizational practices that are extremely well-designed to carry out their required tasks. Neither of these practices label all of their regulations, principles, and activities that govern similar data and information throughout its lifecycle of an organization. The two most common terms that are often used are data governance and information governance even though their definitions are completely different. In this case, data governance is in charge of managing data resources in order to ensure they meet their organizational quality and integrity standards. It also allows you to install trust with your patient’s data and information, which can become important when making patient care decisions.
The principles of documentation is clear, confidential, accurate, complete and concise, objective, organized and timely. Using documentation nurses are required to legally and ethically keep all information in the patient record confidential. There is the Health Insurance Portability and Accountability Act, known as HIPAA, which helps gives patients a greater control over their health care record (). Precise measurements and times must be used as much as possible. Accuracy can be enhanced through point of care documentation (Craven, 2017). The accuracy of documentation can be view from three perspectives veridical reflection of nursing, comprehensive while through detail of a patient journey and finally clarity in usage terms (Britain Summer of Nursing). The accuracy part is the really vital part in documentation within nursing because it shows the complete reflection of the stages of care that was provided by the health care professionals to an individual. Next, when an individual is documenting it needs to be complete and concise and organized. Having the report done as so allows for any health professional to find any information quick as possible without having to search throughout the entire chart for answers. When reporting it needs to be in a chronical flow order of the information about the patient care and procedures being done, within the chronological