What elements should be contained in a medical record and who owns this record.

Question Description

part one

 

Health care records have become an integral part of the effective treatment of patients in all areas of health care. As many health care facilities rush to convert to digital electronic medical records, many have asked the question “What is or should be in a medical record?” An added consideration to this discussion is who actually owns an electronic medical record: the records company that hosts the record in the ‘cloud’, the physician, the patient, the hospital, etc.

Additionally, patient confidentiality is extremely important to all health care workers, regardless of whether they are clinical or administrative workers. This confidentiality is so important that federal policy has been created to help ensure that patient privacy is upheld. This federal policy is the Health Insurance Portability and Accountability Act, commonly known as HIPAA. Many of you have experience with HIPAA from a provider standpoint as well as your own individual experiences in health care practices.

In an original post of 200 words by Midnight Thursday EST identify:

  • What elements should be contained in a medical record and who owns this record.
  • Two changes you would make to current HIPAA policies and why you would make these changes

Please complete two peer replies by Midnight Sunday EST of 75 words each.

Remember that responses to instructor comments do not count toward the minimum post requirements. Failure to meet the assignment instructions, submit posts in a timely manner, respond to an instructor comment, or provide citations and references for all source material will result in loss of points. Do not use quoted or copied material for discussion posts.

Part two

Using the case that you reviewed for your final assignment, what steps could have been taken to reduce the risk to the individuals involved in the case? How could the case have been avoided? Remember, stick to the facts of the case – this is not opinion based.

Complete an original posting of 200 words and two peer replies of 75 words by Module closing. Please see the course snapshot for Module closing dates.

Remember that responses to instructor comments do not count toward the minimum post requirements. Failure to meet the assignment instructions, submit posts in a timely manner, respond to an instructor comment, or provide citations and references for all source material will result in loss of points. Do not use quoted or copied material for discussion posts.

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