Darol Burdge HS420 Unit 4 Assignment - Running Head EVALUATING HEALTH INFORMATION Evaluating Health Information Standards and Regulations Darol Burdge

Darol Burdge HS420 Unit 4 Assignment - Running Head...

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Running Head: EVALUATING HEALTH INFORMATION 1 Evaluating Health Information Standards and Regulations Darol Burdge Kaplan University HS420-01 1/30/2017
EVALUATING HEALTH INFORMATION 2 Evaluating Health Information Standards and Regulations In order to ensure the quality of information that is gathered at a health care facility, specific standards and regulations need to be in place. These standards and regulations need to be followed by all members of the facility. This ensures that the data is accurate when it is input into the patient health record and that it remains accurate as it is accessed between different medical providers and clinics. By adhering to these standards and regulations and by periodically testing our data systems, we can ensure that the information within our health care system remains both accurate and complete. To ensure the quality of care within a healthcare facility it is imperative that all healthcare records are consistent, complete and current. This also ensures that services are billed correctly and that patients receive the proper benefits from their insurance groups (Noridian Medicare Portal, 2015). In order to ensure the accuracy of our health records the following ten requirements must be met for all patient records. 1. Every page of the medical record must contain the patients full name and/or identification number. Doing this will ensure that any hard copies of a patient’s medical record can be identified and processed properly. This also helps to avoid any mistakes where documents may become shuffled together (NCQA, n.d.). 2. All significant illnesses or medical conditions will be listed on the problem list within the health record. This ensures that all providers know exactly where to look to see significant health concerns for all patients (Noridian Medicare Portal, 2015). 3. All medication allergies and adverse medical reactions will be noted on the first page of every health record. If a patient has no known allergies this will also be annotated. Doing this will allow medical providers to see these reactions in advance while
EVALUATING HEALTH INFORMATION 3 annotating that a patient has no allergies will allow providers to know that the information isn’t missing (Noridian Medicare Portal, 2015). 4. The patient’s past medical history will be annotated at the beginning of the health record. This will include previous medical procedures, serious illnesses and accidents. This information can be used by the medical provider for both diagnosis and treatment plans if either is influenced by the history of the patient (NCQA, n.d.).

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