Why is the identification of patients and patient records so important to patien

Question

Why is the identification of patients and patient records so important to patient care and the release of patient information?
What are some good examples of poor documentation practices in patient records and why would these practices cause problems in the future of the patient’s record?
Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record. Why is the identification of patients and patient records so important to patient care and the release of patient information?
What are some good examples of poor documentation practices in patient records and why would these practices cause problems in the future of the patient’s record?
Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record.
What are some good examples of poor documentation practices in patient records and why would these practices cause problems in the future of the patient’s record?
Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record.

Explanation / Answer

Why is the identification of patients and patient records so important to patient care and the release of patient information?

Ans:Patient identification and patient record to an intended treatment is an activity that is performed routinely in all care settings. Risks to patient safety occur when there is a mismatch between a given patient and components of their care, whether these components are diagnostic, therapeutic or supportive. Throughout health care, the failure to correctly identify patients and match that information to an intended clinical intervention continues to result in wrong person, wrong site procedures, medication errors, transfusion errors and diagnostic testing errors.Ongoing, focused management and oversight of healthcare patient identification is critical to both internal operations and regional and national HIE efforts. Well-integrated front-end and back-end workflow processes offer optimal control of this function, which is set in motion with both a patient’s initial and recurrent presentation to a healthcare provider for services. Everyone can be benefited if each and individual patients identification would be recorded, So that it can be useful for future reference ,medical bills,improving their health etc.

What are some good examples of poor documentation practices in patient records and why would these practices cause problems in the future of the patient’s record?

Ans:Throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. When documentation is accurate and complete, it works wonders at telling a patient's story and can even improve patient care. "That story is used in many forums, with the most important being physician-to-physician communication," says Gina Stewart, RN, BSN, CCS, CCDS, a clinical documentation improvement (CDI) practice director and senior consultant at e4 Services. "The documentation in the medical record needs to be complete and accurate to facilitate effective continuum of care."

In general, Stewart says poor documentation is defined as that which is lacking clarity, specificity, or completeness, and is of overall poor quality.poor documentation is anything that inhibits a clear presentation of a patient's story,

Although documentation serves many purposes, Siegel believes its major focus is to provide effective patient care. Failure to properly document can have severe consequences, resulting in the following:

• incorrect treatment decisions;

• expensive, painful, and/or unnecessary diagnostic studies; and

• unclear communication between consultants and referring physicians, resulting in a lack of follow through with evaluation and treatment plans.

Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record.

Ans:For years healthcare organizations have struggled to define their legal health records and align them with the designated record set required by the HIPAA privacy rule. Questions often arise about the differences between the two sets because both identify information that must be disclosed upon request.

These input systems may include laboratory information, pharmacy information, picture archiving and communications, cardiology information, results reporting, computerized provider order entry, nurse care planning, transcription, document imaging, and fetal trace monitoring systems, as well as a myriad of home-grown or individual clinical department systems.

However, the same criteria that organizations used to determine what paper records to retain and include in their legal health records and designated record sets can be applied to electronic records. Questions organizations must ask include:

This practice brief compiles and updates guidance from four previously published practice briefs to provide an overview of the purposes of the designated record set and the legal health record and helps organizations identify what information to include in each. It also provides guidelines for disclosing health records from the sets. The four original practice briefs are listed in the "Sources" section at the end of this practice brief.

The legal health record serves to:

Guidance for Defining Record Sets:

1. Identify Relevant Regulations, Standards, and Laws

2. Determine Records Created in the Course of Business

3. Address Retention Requirements

4. Consider How Data Would Be Produced

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