Medical Records and Charts

Medical Records and Charts

History of Medical Records and Charts in Healthcare

The earliest medical records are linked to ancient Greece and Egypt. The 20^th Century saw the highest adoption of medical records, for instance, the tabulation machine developed by Herman Hollerith. Electronic medical records were introduced in the 1960s after Larry Weed’s Problem Oriented Medical. The HIPPA was introduced in 1996, and the concept of meaningful use has contributed to the use of electronic medical records and charts. Hire our assignment writing services in case your assignment is devastating you.

What is Included in Medical Records and Charts

Medical records and charts include clinicians’ notes on the patient’s demographics, previous healthcare providers, previous and current care plans, pending diagnoses, any history of diseases in the family, and dates of all previous medical encounters, medications, and vaccinations. The medical records and charts may also include the history of the patient’s current health condition since diagnosis; all physical examinations carried out on the patient, pending orders, and social history.

Pros and Cons Of Paper Vs. Electronic

The conversion from paper to electronic-based health records is beneficial in healthcare in various ways. Paper records can only be accessed from one point by one care provider at a time, while electronic health records allow for remote access. Paper records take a lot of time to update, while electronic records can be updated automatically. Electronic records also allow multiple access and sharing, promoting efficient collaboration among various healthcare professionals (Bardram & Houben, 2018).

Importance of Using Medical Records and Charts

Medical records and charts facilitate the provision of consistent care services throughout the continuum of care. Examples include; when a provider is changed or transferred, subsequent caregivers can continue with the provision of required services based on recorded medical history, a new physician can easily provide emergency care services and treatment based on medical records, and caregivers can provide and receive peer support by use of medical records during transitional care.

Importance of the Joint Commission

The Joint Commission plays an important role in healthcare. It ensures that healthcare providers deliver quality and safe healthcare services to patients minimizing patient harm and improving patient advocacy (Wadhwa & Huynh, 2022). The Joint Commission is mandated with the accreditation and certification of healthcare organizations and other healthcare initiatives in the United States. Accreditation and certification from the Joint Commission significantly impact the health organizations’ reputation.

Importance of HIPAA

HIPAA is an essential piece of legislation that not only improves insurance coverage for individuals in the U.S but also supports the transition of the U.S. health records systems from paper-based to electronics-based. HIPAA is vital in the prevention of fraudulent claims in healthcare. It also has provisions that maintain patient information privacy and provide guidelines for accessing and sharing protected health information (Moore & Frye, 2019).

Role of Joint Commission and HIPAA Creation of Medical Records and Charts

The Joint Commission and HIPAA play a critical role in creating medical records and charts. The Joint Commission accredits and certifies healthcare facilities and organizations that are authorized to provide healthcare services, therefore, collecting patient information. The HIPAA regulates the collection and storage of patient information by these accredited healthcare facilities. The HIPAA also regulates the safety and privacy requirements for collecting and storing patient information.

Why One Size Does Not Fit All in Electronic Medical Records (EMR)

A one-size EMR does not fit all in healthcare. This is due to the increasingly complex healthcare needs requiring specific approaches to care. Different health needs require different healthcare specialties, data, and collaborative systems to manage. This means that healthcare professionals will need EMR systems customized in terms of data field layouts, data categories, context menus, and systems interoperability to meet their specific roles in patient care.

References

Bardram, J. E., & Houben, S. (2018). Collaborative Affordances of Medical Records. Computer Supported Cooperative Work: CSCW: An International Journal, 27(1), 1–36. https://doi.org/10.1007/S10606-017-9298-5/FIGURES/14

Moore, W., & Frye, S. (2019). Review of HIPAA, Part 1: History, Protected Health Information, and Privacy and Security Rules. Journal of Nuclear Medicine Technology, 47(4), 269–272. https://doi.org/10.2967/JNMT.119.227819

Wadhwa, R., & Huynh, A. P. (2022). The Joint Commission. https://www.ncbi.nlm.nih.gov/books/NBK557846/

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Create a PowerPoint presentation that addresses each of the following points. Be sure to completely answer all the questions for each bullet point. Use clear headings that allow your professor to know which bullet you are addressing on the slides in your presentation. Support your content with at least three (3) citations throughout your presentation. Make sure to reference the citations using the APA writing style for the presentation. Include a slide for your reference at the end. Follow best practices for PowerPoint presentations related to text size, color, images, effects, wordiness, and multimedia enhancements. Review the rubric criteria for this assignment.

Medical Records and Charts

In a separate Word document, create speaker notes to explain your slides (minimum 50 words per slide). Include a slide for your reference at the end. Follow best practices for PowerPoint presentations related to text size, color, images, effects, wordiness, and multimedia enhancements. Review the rubric criteria for this assignment.

After researching information on medical records and charts, prepare a PowerPoint making sure at a minimum you cover the following areas:

History
Describe what medical records and charts include.
Provide pros and cons of paper vs. electronic.
Importance of using medical records & charts – Give three detailed examples.
Why is the Joint Commission important? What do they do?
Why is HIPAA essential and what does it do?
How is the Joint Commission and HIPAA involved in the creation of this tool?
With electronic medical records (EMR), does one size fit all? Why or why not?
Assignment Expectations

Length: Your PowerPoint should be between 17-and 25 slides; answers must thoroughly address the prompts/questions in a clear, concise manner

Structure:

Title slide and reference slides in APA style (at least 1 slide each)

History (3-4 slides)

Medical Records/Charts Include (3-4 slides)

Paper/Electronic (2-3 slides)

Importance (3-4 slides)

Joint Commission (1-2 slides)

HIPPA (1-2 slides)

Joint Commission/HIPPA (1-2 slides)

EMR (1-2 slides)

Additionally, because a good presentation has few words on the slides, include a script with the verbiage you would say when presenting; the script should be a minimum of 50 words per slide and saved to a Word document.

Review the rubric for further criteria to obtain the best possible grade.

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least three (3) scholarly citations to support your claims.

Format: Save your script assignment as a Microsoft PowerPoint document and a Word document (.pptx) and (.doc or .docx).

File name: Name your presentation file according to your first initial, last name, and the assignment number (for example, “RHall Assignment 1letter.pptx” or “RHall Assignment 1memo.pptx”)