University of Phoenix Material

Health Record Worksheet

In 150 to 350 words, explain the importance of a health record. Support your explanation using your assigned readings.

Personal health records can help a provider's patient better manage their care. Having important health information, for example, immunization records, lab results, and screening due dates in electronic form makes it simple for patients to update and share their records. Patients can be more engaged with their wellbeing and health care. PHRs can advance better health care by offering patients some assistance with managing information from different providers and enhance care coordination. Having an online PHR can be useful if there should be an occurrence of crises particularly if a patient is traveling. Administrative expenses can be reduced utilizing a PHR to give patients simple access to electronic prescription refill and appointment scheduling applications. With PHRs, health care staff can invest less time searching for patient-requested information and respond to patient inquiries.

Use the following table to identify and list at least five key components of a health record. Additionally, include a 50- to 100-word description of each component. Support your descriptions using your assigned readings.

|Component of the health record |Description |
|Patient Management |Required for patient registration, admission, transfer and discharge functionality. |
| |Patient registration includes key patient information such as demographics, insurance |
| |information, contact information etc. |
|Clinical History |CPOE permits providers to enter orders that are required for patient management |
| |specifically in the computer. This component can make use of clinical decision support |
| |tools, for example, drug-drug, drug-allergy, and drug-diagnoses associations. This |
| |additionally permits providers to enter various requests from order sets. Electronic |
| |documentation by providers allows them to document notes such as History & Physical, |
| |consults, discharge summaries, operative notes etc. Multiple tools may be used to enable |
| |electronic documentation such as templates, speech recognition and transcription services.|
|Test Results |Lab components are typically divided into two subcomponents; 1) Capturing results from lab|
| |machines, and 2) Integration with orders, billing and lab machines. The lab component may |
| |either be integrated with the EHR or exist as a standalone product. |
|Radiology Information System |Radiology information system (RIS) and Picture Archiving & Communications System (PACS) |
| |are used to manage patient workflow, ordering process, results and the images themselves. |
|Billing System |The billing system (hospital and professional billing) is used to capture all charges |
| |generated in the process of taking care of patients. These charges generate claims, which |
| |is submitted to insurance companies, tracked and completed. |

Use the following table to identify and list at least five structured coding systems. Additionally, include a 50- to 100-word description of each system. Support your descriptions using your assigned readings.

|Structured coding system |Description |
|International Classification of Diseases, |the standard diagnostic tool for epidemiology, health management and clinical purposes. This|
|(ICD-9-CM &I ICD-10-CM |includes the analysis of the general health situation of population groups. It is used to |
| |monitor the incidence and prevalence of diseases and other health problems, proving a |
| |picture of the general health situation of countries and populations. ICD is used by |
| |physicians, nurses, other providers, researchers, health information managers and coders, |
| |health information technology workers, policy-makers, insurers and patient organizations to |
| |classify diseases and other health problems recorded on many types of health and vital |
| |records, including death certificates and health records. |
|Current Procedural Terminology, (CPT-4) | A medical code set that is used to report medical, surgical, and diagnostic procedures and |
| |services to entities such as physicians, health insurance companies and accreditation |
| |organizations. |
|Health Care Common Procedural Coding System, |A set of health care procedure codes based on the American Medical Association's |
|(HCPCS) |Current Procedural Terminology (CPT). |
|Code on Dental Procedures and Nomenclature, |One use of the CDT Code is to provide for the efficient processing of dental claims, and |
|(CDT-2) |another is to populate an Electronic Health Record. The CDT Code is also used on paper |
| |dental claims, and the ADA's paper claim form data content reflects the HIPAA electronic |
| |standard. |
|National Drug Codes (NDC) |A unique 10-digit, 3-segment numeric identifier assigned to each medication listed under |
| |Section 510 of the US Federal Food, Drug, and Cosmetic Act. The segments identify the |
| |labeler or vendor, product (within the scope of the labeler), and trade package (of this |
| |product). |

References

Ahimaorg. (2003). Ahimaorg. Retrieved 8 February, 2016, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005426.hcsp?dDocName=bok3_005426

Accidentalspeculationcom. (2016). Accidentalspeculationcom. Retrieved 8 February, 2016, from http://www.accidentalspeculation.com/blog/2013/12/28/basic-components-of-an-electronic-health-record