Please use this template to answer the questions below in essay format. The minimum word count for the three questions of Part 1 is 300 words total (or 100 words per question). A reference citation is required.
Your responses should follow the conventions of Standard American English (correct grammar, punctuation, etc.). Your writing should be well ordered, logical and unified, as well as original and insightful. Your work should display superior content, organization, style, and mechanics. Use the APA style only for citations. More details can be found in the GEL 1.1 Universal Writing Rubric.
PART I: MEDICAL RECORDS QUESTIONS
The Medical Record Management System your office implements is only as good as the ease of retrieval of the data in the files. Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.
1. 1. Why are medical records important? (See Chapter 14, page 238–239 of your text for the reasons.)
Medical information is the lifeblood of the healthcare delivery system. The medical record contains all of the medical information that describes all aspects of patient care and serves as a communication link among caregivers. Documentation in the medical record also serves to protect the legal interests of the patient, healthcare provider, and healthcare facility. Medical records are important to the financial well being of the facility as they substantiate reimbursement claims. Other uses of medical records include provision of data for medical research, education of health care providers, public health studies, and quality review.
2. 2. Discuss the pros and cons for the various filing methods? Be sure to include information regarding potential time involved, staffing, and spacing (See Chapter 14, pages 257–259 of your text). Clinical outcomes include improvements in the quality of care, a reduction in medical errors, and other improvements in patient-level measures that describe the appropriateness of care. Organizational advantage, on the other hand, have included such items as as financial and operational performance, as well as satisfaction among patients and staff who use Electronic filing. Electronic filing also cuts down on the space needed tremendously, they no longer need a huge room to store all patients files. It is also faster to find, update, and send electronic files. Last but not least, societal outcomes include being better able to conduct research and achieving improved population health. Although it seems there could be nothing wrong with EMR, there are potential disadvantages associated with this technology. These include financial issues, changes in workflow, temporary loss of productivity associated with EHR adoption, privacy and security concerns, as well as access.
3. Discuss and explain the five basic filing steps. Include why each step (conditioning, releasing, indexing, etc.) is important. (See Chapter 14, pages 255–256 of your text).
Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing steps. (1) Conditioning, involves removing all pens, brads and paper clips. During this process you will also staple all related material together, and attach clippings or items smaller then page-size to a regular sheet of paper. This step is important because your starting to organize and layout the medical record. (2) Releasing, during this step a marking is placed on the papers indicating that they are ready to be filled. This step is important for other members in the medical facility dealing with the filing process.
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