Question

This chapter outlines the purposes of the health record and its transition from paper, to hybrid (combination paper and electronic), to a fully electronic format. It addresses the definition of the legal health record (LHR) and the importance of each organization defining its LHR, although the definition will vary from one organization to another. The LHR will also differ from the organization’s designated record set (DRS). This chapter also identifies the many users who need to access patient information and for what purposes. Focusing on the laws and standards that govern the maintenance of records and the manner in which records are documented and compiled as the business record of the organization, the chapter discusses the principles and guidelines related to the maintenance, content, and documentation requirements necessary to support a legally sound health record whether that record is paper-based or electronic. Principles related to record authentication and attestation, accuracy, authorship (including cut, copy and paste), abbreviations, legibility, changes, timeliness, and completion are discussed. The chapter concludes with a discussion of the life cycle of the health record from identification and creation to retention and eventual disposition based on relevant laws and organizational needs.

1. Discuss at least three purposes of the health record. How would you rank each of the purposes in terms of importance? Explain how you arrived at your decision.

2. Why is the identification of patients and patient records so important to release of patient information and patient care?

3. What are three examples of poor documentation practices in patient records? Why are these practices problematic? Distinguish among the three examples you have given, stating why one is worse than the others.

4. Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record.

5. Describe the purpose of the Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) and the Uniform Electronic Transaction Act (UETA). How are they similar to one another? How do they differ from one another?

Answer 1

Ans:- purposes of health recods are divided into two primary and secondary.primary purposes are

1)patient care delivery

2)patient care menagement

3) patient care support

And zecondary purposes are 1)education

2)research

3) public health and homeland security.

Ranking the purposes according to their importance is also made by the healthcare team members. Each and every information of the specific patient data are collected and kept safely in that health record. And we should keep the health record according to importance.

Lets see one example, firstly patient care delivery, what patient needs and should specify which patient needs more pay attention and yearly wise should be keeping if we kept patient recird data after patient gets discharge.

-patient record data should be ranked prioritywise in order to deliver patient care more efficiently.