Medical or patient Records

Sources must be cited in APA format. Response is to be four (8) double-spaced pages or more / 4 pages for each PART.

PART 1

A 30-year-old male is admitted to the hospital after an evaluation in the emergency room. After undergoing a series of blood tests and a kidney scan he is diagnosed with HIV/AIDS. After three days of receiving intravenous fluids and antibiotics, he is discharged home in fair condition.

The hospital uses electronic processes to retrieve and store patient records.

1. If you were performing an analysis of this medical record, you would expect to find several documents and clinical evaluations. But before you do, you think about the application of The American Health Information Management Association (AHIMA) and its impact on documentation standards and how these types of cases may impact your career going forward. 

Explore the history of health information management (HIM) and the AHIMA organization and then answer the questions below.

A. Make note of the   definition for HIM, and review AHIMA’s history, mission, and future      predictions. Then, discuss documentation guidelines developed by AHIMA,   how do they  apply to the scenario described above.

B. Describe how the recent   and future technological changes in health records management has/will  impact career path as a health care professional. You may use  the AHIMA website as a resource (www.ahima.org).

PART 2

 

As the HIM supervisor, you are asked to educate staff on key concepts related to the release of information and patient disclosures, such as accurate system data entry, data quality, and authorizations and consents. You are also asked to discuss how the release process is initiated through the retrieval of information through the master patient index; and the affect system entry errors and duplicates. The master patient index (MPI) organizes patient information in relation to record processing procedures.

1. Explain the purpose of the MPI and how to correct MPI errors. Provide at least 2 specific examples of MPI errors, their possible causes, and explain how you would correct them.

2. Explain the concept of data quality. Describe at least two ways that the quality of data can affect patients. Be specific.

3. Explain the difference between authorization and consents, and their implications on the release of different types of patient information.