- What are The Joint Commission’s requirements regarding a patient’s medical record? Why is it vitally important to enter information in a patient’s record in a timely and correct manner?
- Describe each of the forms that comprise a patient’s administrative data. Explain the purpose of each form.
- Discuss the various types of consent forms and the reasons they are used.
- What information is included in a patient’s emergency record and discharge summary? Why must this information be timely and accurate?
HTH 2304, Introduction to Health Information Management 1
Upon completion of this unit, students should be able to:
2. Apply compliance standards related to health information to medical records in health care facilities.
2.1 Discuss The Joint Commission requirements and other legal aspects regarding medical
records.
3. Explain the use of indexes and registers for health data collection.
3.1 Discuss summary notes, informed consent, and other patient data.
Course/Unit
Learning Outcomes
Learning Activity
2.1
Chapter 6
Unit IV Essay
3.1
Unit Lesson
Chapter 6
Unit IV Essay
Chapter 6: Patient Record Documentation Guidelines: Inpatient, Outpatient, and Physician Office
Unit Lesson
Health Care, Providers, and Patient Records
This unit covers the content of the patient record and how it is handled by the health care providers. The
health care industry provides medical care mainly in two medical settings: inpatient and outpatient. The health
care delivery system employs large numbers of health care providers in these two settings (e.g., hospitals,
physician’s offices, and ambulatory facilities), and those providers deal with patients’ records constantly
(Bowie, 2019). Every facility is set up differently, and the policies and procedures when handling patients can
be different as well. To ensure that each facility provides effective patient care, these providers are
responsible for maintaining an accurate and up-to-date medical record for each patient who receives medical
care. There are a significant number of mandates (e.g., federal and state laws and regulations) and
accrediting agencies that provide guidance about patient record content requirements in all levels and types
of care (e.g., inpatient, outpatient). All of these factor into the protocols and procedures that the health care
facility follows (Bowie, 2019). As a student in the health care field and a soon-to-be professional in the field,
knowing the protocols and procedures is one of the most important steps to make sure that the day-to-day
tasks run smoothly.
UNIT IV STUDY GUIDE
Content of the Patient Record
HTH 2304, Introduction to Health Information Management 2
UNIT x STUDY GUIDE
Title
Since these laws and regulations hold health care providers accountable for maintaining and managing
patient records, all medical facilities must establish and manage a forms design and control procedure, along
with a forms committee, to ensure that the patient record documentation process is effective (Bowie, 2019).
Management has really big shoes to fill when it comes to holding staff accountable for their actions. For
instance, at most health care facilities, when an employee violates certain rules, the procedure is completed
as follows for the employee: 1) warning, 2) suspended without pay for certain time period, and 3) terminated.
The health care facility wants to keep employees, but it cannot tolerate the breaking of rules by any means. If
employees are completing their jobs as addressed in the medical provider’s procedure manual, rules will not
be broken. This also helps establish excellent patient care.
One of the essential criteria of delivering effective
patient care is to ensure efficient access to a
patient‘s medical records. For example, having
immediate feedback on lab results changes the
dynamic between attending physicians in the
hospital and a patient’s personal physician who also
is able to see lab results in real time. For patients, it
is important to have access to their medical file at
any given time. For instance, most health care
facilities have an electronic setup that allows the
patient to be able to view their medical records at
any given time. Allowing patients to view their
medical records helps with the overall medical
treatment and the patient’s understanding of that
treatment plan.
Electronic record management is a new phenomenon for health care providers. Moving from the use of paper
records to electronic records, some providers are not eager for the change. One reason behind the slow
movement is the cost associated with the paper to electronic transition. It can be costly to implement these
types of programs, not only monetarily, but the training involved can also impact organizations. Many
providers have been cautious or are taking a cautious approach to implementing electronic records.
Implementing electronic records should be a carefully planned exercise in which practice leaders and staff
have to learn new ways to perform some of their tasks to maximize the technology’s efficiencies. This, in turn,
means increasing practice efficiency overall While there are some benefits to paper record-keeping,
technology has greatly enhanced the process as well as reduced mistakes in the storing, editing, and
transmitting of patient data with the implementation of electronic health records. Having an electronic system
allows access to patients’ records to outside entities across the system. This improved communication can
help in clinical decision-making as health care facilities now have more information on patients’ previous
health conditions and treatments that have been performed.
General Documentation Issues
Health care providers must comply with laws, regulations, and guidance established by federal, state, and
accrediting agencies. For example, The Joint Commission standards require that patient records contain
patient-specific information appropriate to the care, treatment, and services provided. Medical records must
contain accurate information to allow the medical facility to complete its job and to give the patient the ability
to obtain any documentation needed. According to Bowie (2019), patient records must contain these data
elements:
• clinical information,
• demographic information (e.g., patient name, gender, and age), and
• other information (e.g., advanced directive).
Other requirements with which the health care providers must comply include ensuring that health care
professionals accurately create the medical records, promptly complete the records, properly file the records,
properly retain the records, and keep the records easily accessible. The health care facility must use a system
of robust patient identification and records that ensures the integrity of the authentication and protects the
security of all record entries (Bowie, 2019). As a result, all clinical and administrative entries are complete,
accurate, authenticated, and dated promptly by the person who is responsible for ordering, providing,
Stethoscope on medical records
(Stojanovic, 2014)
HTH 2304, Introduction to Health Information Management 3
UNIT x STUDY GUIDE
Title
evaluating, and monitoring the medical services furnished. Each entry must also include an authentication,
which means the person making the entry must include his or her signature, initials, or login for computer
entry (Bowie, 2019). This is essential to the care of patients and the documentation of the patient encounter.
Information from evaluation of the patient to the treatment of the patient should always be a part of the
medical record.
As stated before, the medical record is one of the most important parts of the medical facility. Without the
documentation, there is no way to tell anything about the previous or current treatment that has taken place
with the patient. The patient record in all medical care settings is a critical asset that documents medical care
and treatment of the patient. Knowing the previous treatments of the patient helps to establish a treatment
plan. It is also important to remember that a patient’s medical record can be considered a legal document
containing patient identification and other important clinical and personal information. This legal document is a
tool when it comes to medical malpractice lawsuits. A medical malpractice lawsuit is when a patient sues a
physician or medical facility for medical issues resulting from the actions of the facility or acting physician.
Recent advancements in health care information technology have allowed medical facilities to further use
electronic medical records to manage the medical record-keeping process. These new technologies save
time spent looking for paper documents and improve transmission of data. The integration of electronic
medical record systems has allowed providers to manage the patient records more effectively than the paper-
based medical record, but at the same time, this integration has also created issues related to the process to
access patient records (Bowie, 2019). With the use of technology, there can be hiccups and technology-
based issues that are not easily fixed. Most health care facilities have put in place procedures to manage
access and authentication of patient medical records in order to adhere with federal and state laws and
regulations. Continuity of care is an important aspect of personal health records (PHRs). This makes sure the
health care professionals and the patient are following the patient’s treatment plan. Being mindful of patient
quality of care is very important to a health care facility, making sure that the patient is happy with the service
he or she has received.
Changing doctors can be very time consuming, since medical records have to be obtained from the old
physician and transferred to the new physician. This can be difficult due to paper records being lost and/or
damaged. With the use of electronic records, this mistake can be easily fixed. With the use of technology,
these situations can be easily overturned. If using paper filing physicians can have a harder time locating the
file but, with electronic filing, this can be done easier. The big reason behind the change was because the
government did not allow physicians to obtain funds from Medicare and Medicaid unless the physician had an
electronic set up. Even though the electronic system has been put into place, there are still issues that are
obvious such as entering wrong information, systems shutting down, and information being easily edited.
Conclusion
Every medical facility is set up differently, and the policy and procedures when handling patients can be
different as well. Each patient will have a record of administrative data, such as the demographics and the
financial information, as well as the clinical data, such as the medical diagnoses, performance of care, and
treatment. It is important to know the roles of the EHR system. In the future, there will only be more
advancements to health care with technology and the use of the EHR system being a major catalyst in those
improvements. This will improve patient care by providing more quality time spent with the patient. Every
health care facility wants to make sure their patients are receiving the best care. This quality of care is
impacted through interactions with the facility’s staff, and physicians.
References
Bowie, M. J. (2019). Essentials of health information management: Principles and practices (4th ed.).
Cengage Learning.
Stojanovic, D. [DarkoStojanovic]. (2014). Medical-appointment-doctor-563427. [Photograph]. Pixabay.
https://pixabay.com/en/medical-appointment-doctor-563427/
- Course Learning Outcomes for Unit IV
Required Unit Resources
Unit Lesson
Health Care, Providers, and Patient Records
General Documentation Issues
Conclusion
References
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