Document, document, document is the word of the day for the topic of patient health records. Each and every time a patient is checked in at an ambulatory center, admitted into an acute care facility or has an encounter with a health care professional or support staff there should be a corresponding electronic or hand-written footprint of the meeting with the appropriate accompanying narrative documented into the patient’s health record. This action protects the patient, the care provider and the facility itself.
Therefore, the initial encounter is arguably the most important. This is because the primary health record is established when the patient first starts to share their demographics, health history and current symptoms along with …show more content…
The secondary health record, which is created not from the patient first-hand, but later by “analyzing, summarizing, or abstracting” data from the primary record, is necessary for insurance claims, patient safety and to assist administration in quality improvement, financial decision making along with other reporting (Gartee, 2011, p. 102). The importance of the initial data being entered timely is accurate and factual is because of its future use and implications from its use in the secondary …show more content…
Health information technology and management (1st ed.). Prentice- Hall
Lassere, M. N., Baker, S., Parle, A., Sara, A., & Johnson, K. R. (2015). Improving quality of care and long-term health outcomes through continuity of care with the use of an electronic or paper patient-held portable health file (COMMUNICATE): study protocol for a randomized controlled trial. Trials, 16(1), 1-16. doi:10.1186/s13063-015-0760-8
O 'Malley, A. S., Draper, K., Gourevitch, R., Cross, D. A., & Scholle, S. H. (2015). Electronic health records and support for primary care teamwork. Journal Of The American Medical Informatics Association, 22(2), 426-434 9p. doi:jamia/ocu029
Sander, R. (2013). Prevention and treatment of acute ischaemic stroke. Nursing Older People, 25(8), 34-39. doi:10.7748/nop2013.10.25.8.34.e438
Tzeng, H., & Yin, C. (2008). Nurses ' solutions to prevent inpatient falls in hospital patient rooms. Nursing Economic$, 26(3), 179-187
Therefore, the initial encounter is arguably the most important. This is because the primary health record is established when the patient first starts to share their demographics, health history and current symptoms along with …show more content…
The secondary health record, which is created not from the patient first-hand, but later by “analyzing, summarizing, or abstracting” data from the primary record, is necessary for insurance claims, patient safety and to assist administration in quality improvement, financial decision making along with other reporting (Gartee, 2011, p. 102). The importance of the initial data being entered timely is accurate and factual is because of its future use and implications from its use in the secondary …show more content…
Health information technology and management (1st ed.). Prentice- Hall
Lassere, M. N., Baker, S., Parle, A., Sara, A., & Johnson, K. R. (2015). Improving quality of care and long-term health outcomes through continuity of care with the use of an electronic or paper patient-held portable health file (COMMUNICATE): study protocol for a randomized controlled trial. Trials, 16(1), 1-16. doi:10.1186/s13063-015-0760-8
O 'Malley, A. S., Draper, K., Gourevitch, R., Cross, D. A., & Scholle, S. H. (2015). Electronic health records and support for primary care teamwork. Journal Of The American Medical Informatics Association, 22(2), 426-434 9p. doi:jamia/ocu029
Sander, R. (2013). Prevention and treatment of acute ischaemic stroke. Nursing Older People, 25(8), 34-39. doi:10.7748/nop2013.10.25.8.34.e438
Tzeng, H., & Yin, C. (2008). Nurses ' solutions to prevent inpatient falls in hospital patient rooms. Nursing Economic$, 26(3), 179-187