Wednesday, September 25, 2013

Week 4 follow up

10M key capabilities of an EHR system:
1. Health information and data
2. Results management
3. Order entry/management
4. Decision support
5. Electronic communication and connectivity
6. Patient support
7. Administrative processes
8. Reporting and population health management

Cloud computing- refers to the delivery of computing resources over a network sold as a metered service, much like buying electricity.

Sunday, September 15, 2013

Week 3

Things to Remember:

Chapter 3
Clinical Data: Documents medical condition, diagnoses, procedures, and treatments.
Administrative Data: Demographics, financial info, consents, and authorizations.

SOAP format:  Subjective, Objective, Assessment, and Plan.

Types of Standards can include Licensure Requirements, Certification Standards, Accreditation Standards, and Facility-Specific Standards.

The Joint Commission:
Accredits a number of different settings.
They do Unannounced surveys.
Annual submission of Periodic Performance Review
Standards for Documentation
Prohibited Abbreviation List

Other accreditation groups include:
American Osteopathic Assc.
Accreditation Assc. for Ambulatory Health Care
Commission on Accreditation of Rehabilitation Facilities
National Committee for Quality Assurance
Others: specialty accrediting groups exist
            DNV--began accreditation in US in 2008, gaining acceptance

Sayles; Health Information Management Technology: An Applied Approach

Sunday, September 8, 2013

Week 2 follow up
This week we did a scavenger hunt using a faux health information database on the NEEHRPERFECT site.  This was practice for using electronic records to see how they were set up  and how to retrieve or find information.  This was so very much nicer than the first week using the copy of paper records to read from.  Hopefully we will be able to do a lot more hands on work with this site as reading about it just is not enough.  I love to be able to actually see the finished product in front of me.  I enjoy being able to pull apart that object and see how all the pieces fit and work together, like a puzzle.  This site is a very useful too for practice.

Sunday, September 1, 2013

Week 1

Reflection question:  What points in the readings 'stood out' as most relevant to your interests and learning?
Chapter 3 started as a review of the different types of health records, types of documentation standards, and regulating agencies.
Useful points to remember:
1. Basic components of the acute care health record:
  Registration record, medical history, physical exam, clinical observations, physician's orders, diagnostic/therapeutic procedure reports, consultation reports, discharge summary, patient instructions, and consents/authorizations/acknowledgements.

We went over each of these types for definition and examples.  We used copies of handwritten or paper records to create deficiency slips to determine what information was missing from the records.  I believe this easily demonstrates the need for records to be electronic.  The writing on many of these was illegible and using a copy instead of an original did not help either. 

2. While all health care settings keep similar documentation, some settings of specializations may keep unique documents that are required or needed.  Such as:  pediatrics compared to hospice care.  While they may keep many of the same basic health record components, there may be special sections.  Hospice may need a special section on rehabilitation, for example.  Pediatrics may need sections on growth and development.

End of week one--


Welcome to my new blog!  I am currently taking classes for an Associates degree in Health Information Technology.  Part of the requirements for one of my classes is to start a Research Notebook or blog.  What this will include are assignment reflections, informational links, research information, and anything helpful for study information.   If you are reading this information as someone who just wandered across this place, then it may not make much sense.  Health Information Technology is explained here on wiki:
Thanks for joining me! ChristyL