...Associate Level Material Appendix A Final Project Overview and Timeline Final Project Overview As Happy Health Medical Clinic’s records manager, create a presentation outlining standard records management procedures for the employees who work in your facility. Note that the purpose of this presentation is not to define what the aspects of records management mean, but to illustrate the practical procedures employees must follow to handle patient records effectively. Review the Final Project description in Week Nine of the syllabus for important details about this assignment. Final Project Timeline You should budget your time wisely and work on your project throughout the course. As outlined below, some assignments in the course are designed to assist you in creating your final project. If you complete your course activities and use the feedback provided by the instructor, you will be on the right track to successfully complete your project. □ Suggested in Week Two: As you conduct your interviews for Appendix B, take note of how a medium-sized facility differs from small and large facilities. Consider how particular types of health care settings necessarily incur different types of records management issues. □ Suggested in Week Three: Choose the type of record format you think is most suitable for Happy Health—your guidelines will need to inform staff how to create new records and how to use the manual effectively. Also, describe Happy Health’s record retention...
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...The Patient Self-Determination Act of 1990 required consumers to be provided with informed consent, information about their right to make advance health care decisions. This act is also called advance directives. The act requires that patients be given information about state laws that impact legal choices in making health care decisions. Health care facilities in every state are required by this act to notify patients 18 or older of their right to have an advance directive in their medical records. Advanced directives include living wills; do not resuscitate (DNR) orders, medical power of attorney, health care proxy, or organ or tissue donation. Every patient must be informed in written form by health care facilities of the laws in their state that are related to advance directives. Every patient has to sign the advance directive notification form stating that they have been informed of their right to have advance directives. This provides proof for the facility that they have informed the patient. This form has made laws concerning patients right’s stricter. Records management procedures have had to make some changes to the way they do things in order to respond to this legislation. They have had to make sure when a patient comes to the hospital that they find out if they have advanced directives. Before this act this was not a question they asked when you came to the hospital. Doctor’s and the health care team have to pay closer attention to what the patient wants and do as...
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...Established by the U.S. Congress in 1996 and made effective July 1, 1997, theHealth Insurance Portability and Accountability Act (HIPAA) is a group of regulationsworking against abuse and fraud in health insurance and the delivery of health care.HIPAA’s purpose also includes improving the health care system’s effectiveness andefficiency, providing for the continuation of health insurance coverage, and deliveringconsequences for organizations and individuals who do not comply with HIPAAregulations (Highmark, 2007). Different representatives and agencies can request, with or without patients’ consent, patients’ protected health information (PHI). PHI isinformation that is connected to an individual and includes name, telephone number,address, date of birth, social security number, name of employer, and/or Medicaididentification number (Green and Bowie, 2005).Many situations arise when the government has the legal obligation or right to a patient’s medical records. For example, state agencies are required to keep records of deaths and births. They must also maintain registries of people who have received adiagnosis of a serious illness like cancer. Disclosures of such information to thegovernment typically do not require an individual’s authorization (Highmark, 2007).Medicaid, Medicare, veteran’s activities, national security and intelligenceactivities, the military, armed forces personnel, correctional institutions and presidential protective services do not require authorization—all...
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...I have noticed that there are a few different differences and similarities between the small, medium, and large facilities when concerning the organization of patient records, charts and files as well as how they may handle loose reports. I seem to have noticed that most facilities including most small, medium and large facilities prefer that all of their loose records are to be permanently anchored within their patient charts so that they may be able to reduce the risk of those loose reports becoming misplaced and/or lost, which seems to make the most sense to me since this would be the best idea to prevent the loose reports from being misplaced and/or lost. However, the different sizes of facilities tend to organize patient files differently according to each particular facility’s policies. The most popular methods of organization that I have seen include chronologically, form numbers, report type, category and most recent. During my review of the interview threads, I have noticed a lot of similarities and a lot of differences in how patient files are organized between the many facilities which is leading me to believe that every facility has their own system. A system that may work for one facility does not work for another facility, especially when many facilities specialize in different medical areas. A small orthopedic facility may organize their patient’s files by last names where as a large hospital facility may organize their patient’s files by a numerical system...
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...In 1990 the Patient Self-Determination Act became effective. The Patient Self-Determination Act was an act that required consumers to be proved with informed consent, information about their right to make advance health care decisions, and information about state laws that impact legal choices in making health care decision. In North America, it is required that all health care facilities notify any patient 18 and over about their right to have an advance directive in their medical records. Living wills, health care proxy, and power of attorney are all included in advances directives. The patient must be notified, in writing, by the facility to any and all federal laws that are for advance directives for the state they are living in. I believe that this is very beneficial to both the patient and facility; as well as the patient medical records. If any problems were to occur during a procedure or surgery, the doctors and any medical personnel would know exactly what the patient would want. For example, my Grandfather had open heart surgery and he signed a DNR also known as a “do not resuscitate” just in case his heart would stop during his surgery, he did not want any type of CPR preformed on him to bring him back to life. People will all have different reasons behind why they choose to have a DNR. If something were to happen, and they did not perform CPR on a patient who was dying, they would have a living will so that all of the patients last wishes were...
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...HCR 210 Entire Course FOR MORE CLASSES VISIT www.hcr210tutor.com HCR 210 Week 1 CheckPoint Patient Self-Determination Act HCR 210 Week 1 DQ 1 and DQ 2 HCR 210 Week 2 CheckPoint Records Administrators and Technicians HCR 210 Week 2 Assignment U.S. Health Care Settings HCR 210 Week 3 CheckPoint Record Formats HCR 210 Week 3 DQ 1 and DQ 2 HCR 210 Week 4 CheckPoint Patient Reports (Appendix C) HCR 210 Week 4 Exercise Career Self-Reflection HCR 210 Week 4 Assignment Interview Data (Appendix B) HCR 210 Week 5 CheckPoint Alphabetic Filing HCR 210 Week 5 CheckPoint Numeric Filing (Appendix E) HCR 210 Week 5 DQ 1 and DQ 2 HCR 210 Week 6 CheckPoint Record Organization HCR 210 Week 6 Assignment Record Controls HCR 210 Week 7 CheckPoint Internet Databases HCR 210 Week 7 DQ 1 and DQ 2 HCR 210 Week 8 CheckPoint Legal Terms HCR 210 Week 8 Exercise Career Self-Reflection II HCR 210 Week 8 Assignment Releasing Protected Health Information HCR 210 Week 9 capstone DQ HCR 210 Week 9 Final Project Happy Health Medical Clinic …………………………………………………………… HCR 210 Week 1 CheckPoint Patient Self-Determination Act FOR MORE CLASSES VISIT www.hcr210tutor.com Resource: P. 10 of Essentials of Health Information Management: Principles and Practices • Discuss, in 250 to 300 words, the effect of the Patient Self-Determination Act on health care delivery. Consider how you think records management procedures have had to respond to this piece of legislation. …………………………………………………………… ...
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...HCR 210 Entire Course FOR MORE CLASSES VISIT www.hcr210tutor.com HCR 210 Week 1 CheckPoint Patient Self-Determination Act HCR 210 Week 1 DQ 1 and DQ 2 HCR 210 Week 2 CheckPoint Records Administrators and Technicians HCR 210 Week 2 Assignment U.S. Health Care Settings HCR 210 Week 3 CheckPoint Record Formats HCR 210 Week 3 DQ 1 and DQ 2 HCR 210 Week 4 CheckPoint Patient Reports (Appendix C) HCR 210 Week 4 Exercise Career Self-Reflection HCR 210 Week 4 Assignment Interview Data (Appendix B) HCR 210 Week 5 CheckPoint Alphabetic Filing HCR 210 Week 5 CheckPoint Numeric Filing (Appendix E) HCR 210 Week 5 DQ 1 and DQ 2 HCR 210 Week 6 CheckPoint Record Organization HCR 210 Week 6 Assignment Record Controls HCR 210 Week 7 CheckPoint Internet Databases HCR 210 Week 7 DQ 1 and DQ 2 HCR 210 Week 8 CheckPoint Legal Terms HCR 210 Week 8 Exercise Career Self-Reflection II HCR 210 Week 8 Assignment Releasing Protected Health Information HCR 210 Week 9 capstone DQ HCR 210 Week 9 Final Project Happy Health Medical Clinic …………………………………………………................ HCR 210 Week 1 CheckPoint Patient Self-Determination Act FOR MORE CLASSES VISIT www.hcr210tutor.com Resource: P. 10 of Essentials of Health Information Management: Principles and Practices • Discuss, in 250 to 300 words, the effect of the Patient Self-Determination Act on health care delivery. Consider how you think records management procedures have had to respond to this piece of legislation...
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...Associate Level Material Appendix F Career Self-Reflection II Medical regulatory and legal compliance are important areas of health records management. Consider how deeply you might be interested in overseeing these aspects of patient information in your professional work. From what you have learned about compliance issues so far, highlight the choices that best reflect your career interests and explain your reasons: 1. I would enjoy the authority for seeing that documents within patient files are complete, legible, and organized appropriately. • True • False because: While this type of authority comes with greater liability, I like knowing that I can personally ensure that the information provided is not only accurate and complete, but is also organized in a manner that is the most beneficial to my facility. 2. I would enjoy the authority for ensuring that patient files are filed accurately. • True • False because: The accurate filing of patient records is vital to maintaining office standards and streamlining the practices of the office. I would want to guarantee that this procedure was followed correctly, as it is necessary for all office members to more accurately perform their tasks. 3. I would enjoy the authority for developing procedures to track and circulate medical records effectively. • True • False because: I enjoy problem solving and finding ways to increase efficiency...
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...Herbal Supplements The FDA should regulate herbal supplements as it ensures safety for the consumer. If taken properly, herbal supplements have great benefits. The problem is that there simply is not enough regulation of the herbal supplements. Many herbal supplements can be dangerous if taken incorrectly. What’s worse, people simply do not have enough information about the benefits and risks of herbal supplements. A great example of the lack of regulation is overuse of Ephedra. A while back, people started taking mass amounts of Ephedra in order to lose weight. It ended in a great amount of deaths, causing the FDA to take measures against makers of medicines containing Ephedra. Because it was considered an herbal supplement, it did not have the same scrutiny as synthetic drugs. Herbal supplements can be just as powerful as synthetic drugs, so the same vigilance in regulation should apply. Also, harmful ingredients sometimes end up in herbal supplements, which present an entirely new risk. If herbal supplements were more closely monitored, there would be a better chance of preventing this from happening. Because of the lack of regulation, consumers do not have any assurance that what they are buying is safe. Consumers need that assurance, especially when it comes to health products. There also is not very much awareness about herbal supplements. People do not realize how powerful some herbal supplements are. Many people hold the mistaken belief that herbal supplements...
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...Associate Level Material Appendix B Office Comparison Interviews One of the reasons that procedures vary for handling patient records is the volume of patients seen on any given day. By comparing and contrasting record management systems in different sized facilities, you will have information to contribute to several activities in this course. By Week Four you should have completed three interviews, which you may conduct in person or by phone. You need to use the list of questions in the table on the next page to gather information about each of the following: • A small medical facility—an office for one or two doctors • A medium-sized facility—a clinic where several doctors work in partnership • A large facility—a hospital or medical center People will be more likely to cooperate if you disclose that the information you want is related to schoolwork, you will not take up much of their time, and none of the information is confidential. Consider introducing yourself with something like the following: Hello, my name is ________ and I need some general information about filing systems for a school assignment. Would it be possible to speak to the person in charge of filing patient records for a few quick questions, or may I call back at another time? If the facility needs proof that you are a student, you must provide your instructor with a name and e-mail address to send a permission notice, and then allow three days for your instructor to send the...
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...CheckPointRecordsAdministratorsand Technicians | Research the roles of a Records Administrator and a Records Technician.Explain in 250 to 300 words how the general duties for handling patient records differ between a records administrator (RHIA) and a records technician (RHIT).Review the Commission on Certification for Health Informatics and Information Management (CCHIIM)Candidate Guide athttp://www.ahima.org/downloads/pdfs/certification/Candidate_Guide.pdfDiscuss three specific examples of competencydifferences between the RHIA and RHIT exams. | 11/23/11 | 25 | The role of a Registered Health Information Administrator, or RHIA, is very important. In this position, one is a critical link between the care providers, payers and patients. An RHIA works in many fields, such as hospitals, multispecialty clinics, mental health facilities, software vendors, consulting services, government agencies, and education. The requirements of an RHIA are: * To be an expert in the managing of patient health information and medical records. * Possession of comprehensive knowledge of medical, administrative, ethical and legal requirements and standards related to healthcare and the privacy of protected patient information. * Participates in administrative committees and prepares budgets. * To interact with all levels of an organization that employ patient data. Slightly different is that of the role of a Registered Health Information Technician (RHIT). Most often found working...
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...Record Formats HCR/210 Jennifer Briscoe May 24, 2013 According to our textbook a traditional patient’s record is known as a source oriented record. What this means is whatever staff generates the records, the records are stored with that department. For example if a nurse generates a record for a patient the record will therefore stay in the nursing department. Reports from a physician are stored in the medical section. The advantage of this is if a physician’s needs to know the results of an x-ray he can easily look under the radiology section. The down fall to this would have to be if a physician wanted to see the patient’s diagnoses they will have to look under every department section to see what information they are looking for. The problem oriented record consists of four components: data, problem list, initial plan, progress notes. An overview of the patient’s information is in the database, while the patient’s problems are in the problem list. The initial plan outlines the actions that will be taken to determine the condition of the patient as well as treatment. The discharge summary is in the progress note. It also details the care of the patient, his or her treatment and response to that care, and the patient’s condition when he or she is discharged Records in chronological order are called integrated records. This type of record-keeping is good for keeping track of how a patient responds to treatment based on results from tests. Problem-oriented records...
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...ADMINISTRATION AND TECHNICIANS Camille Patch HCR/210 September 14, 2014 Connie Anderson ADMINISTRATION AND TECHNICIANS In this research paper I will be discussing the job that I want to do when I get my associates degree. The job that I want to do will be Medical Record Administration. I will be discussing what the job title and also if there are any jobs in New Hampshire. What Medical Record Administration job responsibility is that it oversees the medical records staff, which is responsible for the maintenance of patient records? Electronic medical records system requires staff to be familiar with health records software and security issues. A medical records administration must be familiar with the legislation to ensure compliance. Medical Record Administration does play a vital role in managing a hospital or clinic. They must perform many supervisory duties and create a safe environment for employees and patients. Most have to work in an entry-level position before attaining a promotion to administration. So far when it comes to jobs in my community, I live in New Hampshire and I have only found one position available. The job title was under Data Analysts: Quality Management. The responsible for this position was to support medical practices and the administration team. I do love this exercise because it made me aware of the qualifications that a medical record administrator does for a living. I had no clue what the position entitles and also...
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...Medical Records I Medical Records Formatting Advantages & Disadvantages Erica Mitchell HCR/210 Mrs. Vivian Rice September 07, 2012 Medical Records II Most facilities and Doctors’ offices keep patient records in a paper format known as manual record keeping. There are nay formats for this particular record keeping SOR source oriented record, POR problem oriented record, EHR electronic health record, CPR computer-based patient record, EMR electronic medical record and optical disk imaging. In Medical Records most records/charts are classified as P.O.M.R OR Problem Oriented Medical Records. The charts are kept together by PN Problem Numbers a number that is assigned to each problem. The records and notes are formatted in S.O.A.P Subjective Objective Assessment Treatment which includes the complaint and illness, physical exams and labs with diagnosis, prognosis of all treatments. An S.O.M.R, source oriented medical record are kept together by the subject of the matter with all labs and progress of notes. Progress notes are always written in paragraph form in SOMR. This record keeping is common for most physicians and hospitals to document these records. The advantages to this record are to make it comfortable for data when organized in sections so anyone can find the information when needed. When looking for past medical records with several visits making it easier to view. In all it makes it easier to view with this traditional formatting...
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...Record Controls By; Jennifer Bradford University Of Phoenix Monica Feigert HCR 210 5/25/12 Keeping a trace of medical records can be a complicated duty, particularly making certain that the records are confined in a confidential area so Health Insurance portability and Accountability Act (HIPPA) legal codes are in assembled and confirming that the legal codes and rules are not impaired anytime. Most of the medical facilities have their own method of achieving these duties. There are some similarities and differences between the dimension of the facility, but regardless all of the medical facilities have an accountability to handle the records and make certain the patients privacy. Since there are different size medical facilities they have different areas as to where they keep the medical records for instance, filing drawer and a private sealed room, or a physician’s desk. Admittance to medical records is restricted to the faculty. Supervising access assist in problems with misplaced records, there would only be a small amount of faculty member who could have moved them, for that reason making it simpler to find. Finding a file can be hard for various reasons like; the file was taken by a faculty member they did what they had to do with the file, then another faculty member takes the file without citing the whereabouts of the file. To prevent these from happening you could have the staff use a check in and check out page. Health insurance portability and...
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