Sarah Stowell
HIT 110 51 N
Chapter 4 Workbook
Chapter 4
Health Record Content and Documentation
Megan R Brickner, MSA, RHIA
Real-World Case 4.1
When Anywhere Hospital began developing its EHR the EHR task force set out to develop an
EHR that will serve as the organization’s legal health record. The unofficial goal of the EHR task
force was to compile all available health information into a single system and provide the means
to deliver the needed administrative and clinical data instantaneously to end users when
needed. Large volume of information, overcrowded computer screens, and lack of uniform
structure soon proved overwhelming for the system’s end users. Their feedback called for useful
and needed health record information formatted in a usable structure.
In response to end-user frustration, the EHR task force took a hard look at the captured
information and how that information was then presented to the end user. The task force
considered the following questions:
●
How is the health information captured, formatted, and structured into one system
when pulling from many sources?
●
How long is health information retained?
●
What information is purged from the system and when is it purged?
●
What health information is archived? Is there any information needed to be kept
permanently?
●
How
much control should end users have over the information they are allowed to
access?
Real-World Case Discussion Questions
1.
What is the role of the EHR task force?
The role of the task force is to develop an EHR which
will serve as the organization’s legal health record by compiling all available health information into one
system for instantaneous delivery to clinical and administrative users.
The task force needs to do a
systems review and determine best practices for ideal results.
2.
Who are the users of the EHR? What do these users need to be able to do in the EHR?
The users
are clinical providers and people working in an administrative capacity.
Clinical providers need to be
able to access relevant health information as well as enter health information.
Administrative users need
to access health information for records request, and verify patient information, and make changes to
demographic info as needed.
3.
How does the legal health record apply to the EHR?
The legal health record is the health record
that is assembled and presented on request.
It must be ascertained that the EHR and the paper record do
not have any discrepancies.
It also must be determined what elements of the EHR are to be included in
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Sarah Stowell
HIT 110 51 N
Chapter 4 Workbook
the legal health record. Like a paper record, it must be determined if the record is authorized to be
released to the requesting party and if the record would be held admissible in court.
- Fall '14
- BarryLangford
