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Essentials of EHR Implementation and Management1Essentials of EHR Implementation and ManagementKyle MasonKaplan University
Essentials of EHR Implementation and Management2When it comes to Electronic Health Record systems (EHR), there is not an easy or sure-fire way in dealing with these complex systems whether it be The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), Centers for Medicare and Medicaid Services (CMS) and/or other services. Their goals and objectives when dealing with EHR should all be the same. Those goals and objectives are improving quality of care, improving safety and efficiency, as well as reduce health disparities. They should also focus on improving care coordination, engaging patients and families in their own care, improve population and public health, and ensure adequate privacy and security protections. There are a large number of existing rules and regulations on documentation guidelines and principles along with new guidelines being recommended every day. A Standard is “an idea or thing used as a measure, norm, or model in comparative evaluations”, while a regulation is “a rule or directive made and maintained by an authority.” Companies or organizations such as TJC put out standards and regulations for their members to follow to achieve their goals and objectives for providing improved patient care and treatment. When documenting patient care there are key areas of information to obtain. 1.Each page in a patient’s record should contain either their name or ID number. Mixing up patient records could have a major impact on the patient missing the document. The improperly filed document may also affect the patient’s record if improperly filed. It could hinder provider care, for example, two patients with a test for a skin cancer come back from the lab and the documents get mixed up. One came
Essentials of EHR Implementation and Management3back positive and the other negative for skin cancer. The patient with the skin cancer needs it removed; however the guy with the negative for skin cancer just got part of his skin cut out for no reason while the other patients continues to grow. 2.Significant medical conditions and illnesses need to be indicated in the chart (preferably in a pre-described position in the chart). Some conditions or illnesses can affect possible treatments for new conditions and. This is important when it comes to