Health care organizations continue to evolve in the use of electronic formats to capture, structure and facilitate the use of health information. In todays healthcare environment organizations can range from entirely manual to entirely electronic, with many falling into a category of hybrid documentation which includes both. As a HIM professional you may have a role in ensuring that as an organization moves along continuum from paper to electronic that the documentation in the health record continues to support the diagnosis and reflect the patients progress, clinical finds and discharge status.
Hospital Wellness is in the process of working with the EHR vendor they have selected to finalize the electronic data capture tools for health record documentation. You have been asked by the Chief Information Officer (CIO), to lead a team evaluate and make recommendations on the information and flow of documentation for the first set of templates that will be moved from paper to electronic.
The manual documentation record and an electronic version are provided in your text in under Sample Documentation Forms-Appendix A, which can be accessed through your website access code. Assume that the manual version meets the documentation guidelines that your facility requires based on their documentation guidelines. Evaluate the electronic version of these documents for capturing and ease of use of the health information by comparing and contrasting it to the existing manual version. Recommend and support your position on whether the electronic version presented should be accepted by your organization. If you do not recommend the proposed electronic version, prepare a recommendation for what additions/deletions/revisions are needed in order to accept the proposed electronic tool. The following data capture forms/tools are to be evaluated. The current manual form is provided first in the list, followed by the electronic. Please prepare a chart or spreadsheet showing you review and recommendations for submission to the CIO.
Admission RecordPhysician OrdersGraphic Vital SignsMedication Administration RecordLaboratory ReportsOperative ReportSurgical Pathology ReportDischarge Summary
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.Save your assignment as a Microsoft Word document.
Health care organizations continue to evolve in the use of electronic formats to capture, structure and facilitate the use of health information. In todays healthcare environment organizations can ra
Sample Authorization to Use or Disclose Health Information Patient Name: ____________________________________________________________________ Health Record Number: ______________________________________________________________ Date of Birth: _____________________________________________________________________ I authorize the use or disclosure of the above named individuals health information as described below. The following individual(s) or organization(s) are authorized to make the disclosure: The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated): ? problem list ? medication list ? list of allergies ? immunization records ? most recent history ? most recent discharge summary ? lab results (please describe the dates or types of lab tests you would like disclosed): _______________________________________________________________________________ ? x-ray and imaging reports (please describe the dates or types of x-rays or images you would like disclosed): _______________________________________________________________________________ ? consultation reports from (please supply doctors names): _______________________________________________________________________________ ? entire record ? other (please describe): _______________________________________________________________________________ I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. The information identified above may be used by or disclosed to the following individuals or organization(s): Name: ______________________________________________________________________ Address: ____________________________________________________________________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ 241 Source: Hughes, G. 2002 (October). Practice brief: Required content for authorizations to disclose. Journal of AHIMA. 6. This information for which I am authorizing disclosure will be used for the following purpose: ? my personal records ? sharing with other healthcare providers as needed ? other (please describe): ______________________________________________________________________ 7. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. 8. This authorization will expire (insert date or event): ______________________________________________________________________ If I fail to specify an expiration date or event, this authorization will expire six months from the date on which it was signed. 9. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 10. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment. ______________________________________________________________________ Signature of Patient or Legal Representative Date If signed by legal representative, relationship to patient _______________________________________________ _______________________________________________ _______________________________________________ Signature of Witness Date Distribution: Original to provider; copy to patient; copy to accompany use or disclosure Note: The types of documents listed on the authorization form may need to be modified depending on the particular health care setting. Authorizations for marketing need to disclose whether remuneration was received by the covered entity. This form was developed by AHIMA for discussion purposes only. It should not be used without review by your organizations legal counsel to ensure compliance with other federal and state laws and regulations.