Question

Develop a policy to ensure that no patient’s information will be accessed without authorization based on the following scenario:

Scenario:

Assume that you are a project manager leading a team of three members who are working on an Electronic Health Record (E.H.R.) project for the local healthcare system. Your team will undoubtedly have access to the sensitive patient information.

Make sure the Policy specifically addresses how to protect patient information in the project development of an E.H.R. system.

? Policy statement

? Procedure identified

Answer 1

Policy statement;

Medical records in digital format.

Provide an electronic health records system for the purpose of conducting business in support of clinical operation and patient care. Allowed electronic record are the property of University of North Texas Health Science Center and UNT health. UNTHSC and UNT health reserve the right at any time to limit, restrict or deny access to EHR system to the extent provides by law.

Content shall be in compliance with standard established by JCAHO joint commission on accreditation of health care organisations and American health information management associated and shall also comply with requirements in third party payment programme or with licensure requirements of special programme. All patients documentation will be entered by provider data entry, transcription, uploading and documents scanning. Electronic stored patient information is subject to the same medical and legal requirements as the hand written information in the health records

The document established guidance for creating and maintaining a quality health records in accordance with sound medical and legal practice and to meet federal, state and local guidelines. The use of electronic health records system will be standardised and utilized in all UNT health clinics sites.

Organize their thinking related to patient problem

Demonstrate their clinical reasoning

More fully participate in patient care.

Teaching physician should be familiar with their clinical sites guidelines on emergency health records

Teaching physician should encourage medical student appropriate use of the emergency medical records to document patient care.

Provide formative feedback for improvement of students performance.

Procedures identification;

Necessity for establishing clear practice

Matching paper and electronic procedures and results

Sample policy contents.

The health records will contain sufficient information to identify the patient diagnosis, treatment, document results

Of care or treatment describe the condition of patients upon discharge and documentation instructions to the patient regarding follow up care, activity levels and necessary medications.

Entries must be accurate ,relevant, timely and complete.

Irrelevant text needs to be omitted. Concise notes are more readable than lengthy notes.

Appropriate note titles must be matched to note content and the credentials of the author. This enhance the ability to find a note more quickly and easily.

Notes must be reviewed and signed promptly

Viewing of unsigned notes is allowed by pharmacy only due to the risk of clinical decision making based on data that may be changed or deleted. Other limited access to unsigned notes may be determined by local policy.

Health information

Medical management

Laboratory management

Diagnostic uses

Referral

Electronic communications

Supportive purpose

Practice report

Auditing the current system

Planning the implementation of EDMUND

Developing contents for documents

Adaptation of the system used

Develop procedures for staff

Can improve to ability to diagnosis diseases and reduce even prevent medical error improve patient outcomes and deliver better patient care.

Make sure examination take place in isolation from other patients, unauthorised family members and staff

Professional trained to collect only the relevant health and of patients with their consent

Clear guidelines to patient on how their personal health information will be used in the medical process. Understand and comply with the law.