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In: Nursing

This week, we are going to examine the importance of medical records. Everyone from the top...

This week, we are going to examine the importance of medical records. Everyone from the top down in a hospital or medical service is responsible for accurate medical records, billing, records release and other documentation.

Please review the materials for the discussion board this week and discuss at least 2 important take-aways that you have learned about from the e-text and the materials. What are the 2 most important things? What laws underpin those things that you learned?

Solutions

Expert Solution

A medical record is an important record prepared by health care practitioners about a consultation or examination or the application of health management techniques in a single patient. It is the systematic documentation of a patient's medical history and treatment details. It includes different types of notes or prescriptions, recorded observations, and details about the application of drugs and therapies, orders for the application of drugs and therapies, tests, referral forms, lab reports, results, x-rays, and other relevant reports, etc. entered by healthcare professionals.

Medical records are very important. Medical records can be used for the following reasons:

  1. Medical records include private information about a person/patient
  2. Medical records help the reimbursement / insurance coverage for health services provided
  3. Medical records provide evidence about injury and treatment for workers’ reimbursement
  4. Medical records provide evidence and proof of disability for the application of disability insurance
  5. Medical records helps to identify the patient who has had undergone a specific treatment and that treatment caused some adverse effects or side effects in their life
  6. Medical records help to study disease trends
  7. A medical record help to identify the possible environmental or genetic reasons for disease.
  8. A medical record helps to track changes in physical findings or the increase or decrease of symptoms/illness.
  9. Ensuring complete and accurate medical records is an important factor for health care providers in their licensing or their certification.

Mainly two laws underpin the importance of medical records:

1.   Health Information Technology for Economic and Clinical Health Act,2009 (HITECH Act)

Key points.

  • This act encourages the conversion of paper medical records into electronic charts.
  • This act supports the adoption and meaningful use of health care information technology
  • This act addresses the patient’s privacy and security
  • Based on these acts, patients must be notified of any unauthorized access or misuse of their medical information.
  • This act addresses the punishments for the non-compliance
  • This act addresses compensation for physicians and healthcare providers.

2.   Health Insurance Portability and Accountability Act,1996.

Key points

  • This act specifies how personal information maintained by the healthcare and healthcare insurance industries.
  • This act addresses the protection of medical records and personal information from fraud and theft
  • This act addresses limitations on healthcare insurance coverage.
  • This act addresses the penalties for medical record issues

In short, Good medical records are essential for the continuity of health care in patients. It also helps in defending a complaint or clinical negligence claim. A complete, up-to-date, and accurate medical record can make a good outcome for both patient and health practitioner.


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