Information Management in Healthcare (HINT 730)

Class: Information Management in Healthcare
(HINT 730).

Your outside reading for this week
discusses the similarities and differences between the LHR (legal health
record) and the DRS (designated record set). For this assignment, you are to
create a matrix in Excel that will capture the information below for the
elements of the patient record in both an inpatient (IP) and outpatient (OP)
setting. Some of the elements will be the same for both IP and OP, others will
only occur in one or the other. You can combine this into one matrix, or create
two separate matrices.

If you are currently working in a hospital
or physician’s office, use real data for this assignment. For example, if your
progress notes for the physician’s office are done in a paper format and then
scanned into the EHR, indicate that on the matrix. For those of you who have never worked in a
health care setting, determine the best practice for the element and its
designation. For this assignment, you
are to create a matrix that will capture the following information (not
necessarily in this order).

Name of the document/record content

Source/media of the document (for example; paper, computer generated,
lab system, financial system, film, video, scanned document, etc.)

Final location of the information. (For example, if only the final
dictated report of an x-ray is in the EHR, but the actual film is housed in
Radiology, indicate that on the matrix. But if an order is created via CPOE,
then the final location is in the order section of the EHR)

Whether it is a part of the LHR, the DRS, both or none.

Note/Comment section.

At a minimum, you should track the
following elements. If you have other
elements that are specific to your workplace, feel free to add them.

·
consent forms, H & P

·
initial office visit

·
progress/office notes

·
consults

·
op notes

·
lab work

·
orders

·
radiology reports

·
radiology films

·
advance directives

·
immunizations

·
medications

·
problem lists

·
discharge summary

·
nurses notes

·
ancillary notes (PT, OT, Social
Service)

·
insurance information

·
EKGs

·
incidence reports

·
autopsy report

·
release of information forms

·
phone calls

·
post-it notes left by a
clinician

·
videos

·
pathology reports

·
reports sent from other
providers

·
information brought in by the
patient

·
billing statements

·
emails from the patient

·
coding queries

·
research data

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