Question

Describe current recordkeeping approaches in clinics or wellness centers. What steps would ensure client access and privacy? How might a third party have access to the consumer’s personal data? Consider factors such as familiarity with content-specific terminology or special populations in regards to helping consumers with their records. Please cite the answers.

Answer 1

ANS: Keeping a record of each and every patient is an integral part of clinics and wellness center It should have continuity and communication with different. Healthcare center it has to be updated and appropriate giving details of all the test and diagnosis of the patient with date time and with doctor’s remark. It can be electronic or on paper should the need arise, patients, themselves should have access to their records to be able to see what has been done and what has been considered. The clinical record is a document for future reference, so it should have continuity with vital importance to patients care it helps a patient from repeating the same test again and again thus it will save his time. Access to his or her own medical records is an indisputable right of every patient. To keep the records privacy certain steps can be taken such1.1.

1. Use a dedicated server.   

2) Encrypt data. ....  

3) Utilize a website malware monitoring service. ....   

4) Restrict access to personal information. ...

5) Shred sensitive paper documents. ..   

6) Use a wiping program. ...

7. Use computer screen facial recognition software. ...   

8) create a plan in case of a breach   

A good record keeping helps the patient in the emergency; it should have a detailed list to simple references. The third party can have access to consumer’s personal data if it is reasonably necessary for the doctor to share the information he can do it with patients consent. But if the patient does not want the information to be shared he should be made aware of the consequences. For legal matter to the information can be shared with the third person. for insurance companies where doctors are asked to write a report about patients or disclose information from existing records for third parties or local authorities.  

The record must mention time date test and procedure done in legible handwriting on paper or it has to properly enter in terminology which is commonly used and understood instead of medical terms which are not in use with common people abbreviation like PID that can stand for prolapsed intervertebral disc or pelvic inflammatory disease, Referral documents should be documented in unambiguous term. For example, if the patient needs to understand the urgency, this should be obvious from the written comments. For example, if the patient needs to understand the urgency, this should be obvious from the written comments.