Question

Health Record Data Managnment

During the past 6 weeks, you have been introduced to multiple knowledge areas, including healthcare environment in the US, healthcare settings, health information profession, professional organizations, and some health data management aspect. This week is dedicated to a review of some important concepts, which you will also see in the mid-term exam. You may start the review by selecting one of the questions below. Please try to read the answers prior to yours and try to address a different question

1. Compare and contrast Conditions of Participation with State Licensing, and Accreditation requirements.
2. Explain two factors that have influenced the delivery of healthcare in the United Stated.
3. Differentiate among acute care, ambulatory care, and long-term care.
4. There are three typical formats for the paper health record: source-oriented, problem-oriented, and integrated health record format. Which format do you favor and why?
5. What does the statement “If it isn’t documented, it was not done.” mean in terms of compliance with health record documentation? What type of issues could lack of documentation create?

Answer 1

Two factors that have influenced the delivery of healthcare in united states are:

1)Technology. technology is credited as having the most significant effect on healthcare delivery.

2. Healthcare product and service prices. The level and growth of healthcare prices have a big impact on healthcare spending and healthcare delivery.

3. Health insurance coverage. Getting health insurance coverage can potentially reduce patients' incentives to seek the most efficient, lowest-priced care .However, the recent trend of employers and insurers placing more fiscal responsibility on patients' shoulders in the form of higher coinsurance and copayments has contributed to slower growth rates and influenced the delivery of healthcare.

----Acute care is an inpatient care wheras ambulatory refers to outpatient care. An acute care is a medical facility in which patients remain under constant care. An ambulatory setting might be a non-medical facility like a school or nursing home, but it also includes clinics and medical settings that typically deal with non-emergency issues.long term care deals with long term care or home based care,dealing with the aged and often frail population thatcomprises long-term care facilities .

Medical records that are used are of three types:

· Problem oriented record

· Source oriented record

· Integrated record

A source oriented record i prefer, where data is organized according to its suppliers or source. because the sources could be individuals like physicians or nurses that are giving the care or even the individual departments or the specialties within the department that are involved with the care process. Nurses have to maintain their set of written documentation where they record their specific roles in the treatment process. All of the individual documentation is further filled for future access.--

--statement“If it isn’t documented, it was not done.” means in terms of compliance that if their is no proper healthcare documentation in record it does not maintain rules for complying in documentation of action.it is the process of making sure your company and employees follow all laws, regulations, standards, and ethical practices that apply to your organization.-

---Issuescould lack of documentation create are following:

1)lack of transparency 2)poor customer interaction3)failure to comply with legal requirements4)Not following the principal of ethics having well documented policies and control is important part of reducing risk that lack of documentation creates.