Cheryl Fahrenholz throughout chapter 2 discusses various laws and acts that govern electronic health records as well as key point related to the documentation of patient records. I picked five that I believe are the most important. clinical documentation and health records, derived data, release of information, legal health records and health insurance portability and accountability act.
Clinical documentation and health records are of vital importance to the success rate of any clinical faciality. Health records of patients provide medical professionals with past medical issues, diagnoses, allergic reactions and past family history. Providing all clinical staff with huge packets of information that with proper observation can lead to more precise treatment. This is beneficial for Emergency Room visits providing information for the doctor that the patient may not be able to communicate with any of the staff. It also provides a full range of every aspect of a patient stay in the hospital. This way if something was done incorrectly, or the patient has concerns, everything is fully documented. This protects not only the patient but the hospital and staff as well.
Derived data is the summarization of a patients stay, giving insight into what was done to them without providing specific …show more content…
Medical professionals will throughout their careers communicate with various persons large quantities of patient information. This is a large contributing factor to a hospitals quality of care but it is important to understand what information is relevant and which is intrusive. The terms retention and destruction are used when talking about release of information. Which is the ability to keep or discard information of non-importance and importance. This way the system does not sore every facet of a patient’s health record and allowing them more