HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study

Discussion 4.1: Outside Influence on Healthcare Documentation

Guidelines

Please make sure your discussion posts include all of the items below:

Summarize what influence outside entities have on documentation standards in healthcare.

Note: your initial summary post should be one or two paragraphs in length (a paragraph is at least 3 sentences in length).

SPC Real World Case 4.1: Anywhere Hospital

Real World Case 4.120 POINTS

For this activity, you will review the Real World Case 4.1 below. Conduct an analysis of the situation and summarize how you would have addressed the issues by answering the questions below.

Analyze Real World Case 4.1:

When Anywhere Hospital began developing its EHR the EHR task force set out to develop an EHR that will serve as the organization’s legal health record. The unofficial goal of the EHR task force was to compile all available health information into a single system and provide the means to deliver the needed administrative and clinical data instantaneously to end users when needed. Large volume of information, overcrowded computer screens, and lack of uniform structure soon proved overwhelming for the system’s end users. Their feedback called for useful and needed health record information formatted in a usable structure.

• In response to end-user frustration, the EHR task force took a hard look at the captured information and how that information was then presented to the end user. The task force considered the following questions:
• How is the health information captured, formatted, and structured into one system when pulling from many sources?
• How long is health information retained?

What information is purged from the system and when is it purged?

What health information is archived? Is there any information needed to be kept permanently?

How much control should end users have over the information they are allowed to access?

Read the case study above and then answer the following questions:

What is the role of the EHR task force?

Who are the users of the EHR? What do these users need to be able to do in the EHR?

How does the legal health record apply to the EHR?

Guidelines

Before you submit your Real-World Case Study written responses:

Ensure all of the Real World Case Study 4.1 questions are answered thoroughly.

View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.

Then, finally, complete and submit your answers in the Quiz Tool.

Please Note: Each question is worth 6.66 points for a total of 20 points. 

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SPC Real World Case 4.2: Anywhere Hospital Copy Paste Function

• Real World Case 4.220 POINTS

For this activity, you will review the Real World Case 4.2 in your textbook. Conduct an analysis of the situation and summarize how you would have addressed the issues by answering the questions below.

Analyze Real World Case 4.2. Read the case study and then answer the following questions.

What should be considered when deciding whether or not to use the copy and paste functionality?

What controls might be put in place related to the copy and paste functionality?

What alternatives to the copy and paste functionality are available?