Running head: IMPROVING quality health CARE ORGANIZATIONS
By : Sandra Hill
health care Organization and Administration 315
Improving Quality Health Care Organizations
health record Documentation Standards and
Foundational Concepts of the Legal EHR and
Data Content for EHR Documentation
Saskatchewan, Saskatoon
Saskatoon Health Region
Carol A. Quinsey, Crystal Kallem, Jill Burrington-Brown, Angela K. Dinh
Journal of AHIMA 78
IMPROVING QUALITY HEALTH CARE ORGANIZATIONS 2
Health Record Documentation Standard and
Foundational Concepts of the Legal EHR and
Data Content for EHR Documentation
Accountable Care Organizations (ACO) is a local health care organization, related
to a set of provider that are held accountable for quality and cost, It’s defines the population
and deliver the coordinated and efficient care it succeeds both delivering high-quality care
and spending health care dollars more wisely, it will share in the saving it achieves for the
The Business plan on Accounts Receivable Management In Health Care Organizations
To increase profit in health care organizations, most companies usually allow the services to be done on credit. There were allowed with the high expectation that customer would pay incurred amount in due time. But there were also times when customers would not pay on time or not be able to pay at all, the expenses then would fall into the uncollectible accounts, or bad debts, and are a loss or an ...
Medicare program.
There are new ACO proposals and concept, which include allowing great flexibility
in both types of organizations, flexibility allows local markets to develop ACO organization
models and payment approaches, concepts drive ACO’s is that it’s providers, is not insures,
and make changing that address the cost and quality problems.
Several types of quality problems in health care are variation in services this is to
continue to be a pattern of wide variation in health care practice, which include regional
variations and small- area variations. It is clear that health care practice has not kept pace
with the evolving science of health care to ensure evidence-based practice in the US. You
also have underuse of services this is where people do not receive necessary care and suffer
needless complications that ass to costs and reduce productivity. Then you have overuse of
services this is where Americans receive health care services that are unnecessary, increase
costs, and may endanger their health. Last we have disparities in quality, this quality may be
most marked for members of ethnic and racial minority populations.
There are additional issues involved in the implementation of ACOs that go beyond
the specifics of any giving program, which are impact on private payers, responsibilities for
providers and government agencies, ACOs provide potential values, and new types of
organization. ACO proponents are concerned that without a serious quality assessment and
reporting component, ACOs might emphasize cost cutting rather than improved value. MedPAC
that quality measures and targets could be aggregated into a weighted quality score.
The reasons for skepticism is the attempts to manage care, health insures to close panels
managed by providers, shared saving payment approach, and weak financial incentives in SSP
payment model. This would not be able to bring together these increasingly independent
professionals, who have interest in preserving the status quo, not participating in substantial
collective efforts for nominal shared savings.
The Dissertation on Three Essays on Health Care
This dissertation has been motivated by the question of how countries should optimally structure health care. Especially, there are two important economic and policy questions asked that extend beyond the area of health economics. The …rst is how the expansion of health insurance coverage a¤ects the utilization and health of its bene…ciaries (extensive margin); the second is how generous should ...
Health record is a Paper – or – Computer – Based tool for collecting and storing information
about the healthcare services provided to a patient in a single healthcare facility; also called a patient
record, medical record, resident record, or client record, depending on the healthcare setting. Health
record shall be maintained for each individual who receives health care services.
The purposes of the health record is to serve as a basis for planning patient/ client/ resident
care and for continuity in the evaluation of the patient/ client/ resident’s condition and treatment;
To furnish documentary evidence of the course of the patient/ client/ resident’s evaluation, care,
treatment, and or change in condition; To document communication between the clinician responsible
for the patient/ client/ resident and any other clinician who contributes to the patient/ client/ resident’s
care/ treatment; To assist in protecting the legal interest of the patient/ client/ resident the organization,
and the clinician responsible for the patient/ client/ resident; and to provide data for use in continuing
education and research.
Huffman (1994) defines a health record as a compilation of pertinent facts of a patient’s
life and health history, including past and present illness and treatment’s, written by the health
professionals contributing to that patient’s care. The health record must be compiled in a timely
manner and contain sufficient data to indentify the patient, support the diagnosis, justify the
treatment, accurately document the results.
The principles of the health record documentation are quality health care services; effective
communication; continuity of care across the health delivery system; accountability; and quality
improvement and research support. In general the health record is; Confidential: it is protected
from unauthorized access, loss and damage. Charts are to be stored in a designated location that
protects privacy but allows authorized access. Contemporaneous : frequency of charting is dependent
upon intensity of service requirements, discipline – specific standards and guidelines, and any
The Term Paper on Patient Portals Impact Patient Care
Patient portals, which are secure web based applications, provide patients the ease of access to their health care records at any time. Some portals include features such as, obtaining prescription refills and lab results, and communicating with their provider. With close to 80% of the population in North America using the internet to seek out health information, portals continue to gain ...
applicable policies and or standards of the program or service. A written entry must NOT be
altered, added or edited on a previous visits record once all relevant information has been compiled
for that visit. Chronological : Ideally, documentation should be entered in chronological order. In
case where a late note must be written, the writer will note the date and time of the entry with ‘Late
Entry’ written beside the date and time. No gap or lines will be left between entries. Complete and
Accurate : All pages of the health record must be labeled with the minimum identifiers of the patient’s/
client’s/ resident’s/ name. HSN and date of birth. This ensures that when the health record is
photocopied or faxed, each page can be correctly correlated with the right patient/ client/ resident.
All entries into the health record must includes : the date (in day, month, and year format), time of
entry (according to the 24 – hour clock), and identifiable signature and the author’s printed name and
designation/ position. Clear : Documentation should clearly communicate the health status of the
individual and result of health services delivered. It should not lead to misinterpretation,
misunderstanding, or miscommunication by any member of the healthcare team or legal
representatives. Factual and Objective : Documentation should reflect a professional attitude
toward the individual and the care/ treatment provided. Appropriate : Documentation will be
based on discipline – specific or department – specific guidelines or standards wherever applicable.
Legible : All entries will be made in ink (black ink preferred for ease of photocopying) and in legible
Handwriting where and electronic health record is not available.
Health record format considerations includes : organization of the record, health record is non-
acute or rural agencies will be organized according to accepted chart (or file) order for the agency /
facility. Computer – based record any electronic versions of the health record will be kept in
accordance with the Guidelines for the protection of health information (COACH 2001).
The Term Paper on Personal Health Records
... “would create a personal health record that patients, doctors and other health care providers could securely access through ... documentation to electronic documentation chaos. Nurses must play an proactive role in educating themselves to the variety of personal health record ... Retrieved March 10th, 2011, from www.acponline.org Personal Health Records Standards. (2010). Retrieved March 13th, 2011, from ...
Transitory health records, media, including digital and film records, are considered to be transitor 5or non – permanent health record. Forms Design in Saskatoon, the clinical forms committee, a
subcommittee of the clinical record committee approves all clinical record forms used for documentation.
Format guidelines are established under organizational policies. (Refer to SHR Policy #7311-20-002:
Standards for Creation/Revision of Clinical Health Record Forms).
Use of the record is health record
should be used for communication among clinicians and support staff. Health record can be used for
research if authorized approval is received by the research services unit (RSU) under strategic Health
Information and Planning Services (SHIPS).
The content of a health record is developed as a result of the interaction of the members of the
health care team who use it as a communication tool. Documentation may be organized according
to the source of the data or by patient problems. There are two basic formats that a paper-based
health record may take : Source oriented medical record information about a patient’s care and
illnesses is organized according to the “Source” of the information within the record, that is, if it is
recorded by the physician, the nurse, of data collected from an x-ray or laboratory test, usually in
chronological order. Problem oriented medical record form of structured health record developed
to meet these criteria. First designed by Dr. Lawrence Weed in the late 1950s, this concept requires
the doctor to approach all the problems of a patient, treating each problem individually, in its proper
context within the total number of problems and the inter-relationship of the problem (Weed, 1969).
Primary function of a hospital, clinic or other health care facility is to provide high quality
patient care to all patients, whether inpatients, emergencies or outpatients, the governing body of
the facility, through the administration, is legally and morally responsible for the quality of care
rendered to patients. This responsibility is in turn delegated to medical, nursing and other health
The Essay on Electronic Health Record 2
Hospitals and other health care providers increasingly rely on cutting-edge technology to provide medical treatments to patients, and a growing number also realize the benefits of technological advances in administration and record-keeping. In the recent past, most health care providers maintained patient records in paper files, eventually transferring the completed records to microfilm for ...
professional staff. It is important that the health information management / health record
professional understands the responsibilities within the clinic or hospital in order to assist the doctor
and other professional to maintain a complete, accurate and available health record.
The concept of a legal health record (whether paper of electronic) is generally well understand
within the HIM profession. However, during the transition from paper to electronic records some
organizations are expressing concern about the use of the terms “legal health record” and “legal
electronic health record.” Health records serve many purposes across every care setting. They are
the basis for communication among healthcare providers, documentation of patient care, the source
of data for patient care evaluation and research for improving the quality of patient care, and the
source for reimbursement for serviced rendered,
Health records contain a wide range of information, but most information within a health
record can be grouped into two main categories; administrative or demographic data and clinical
data, Existing data standards, sample documents, and industry publication were evaluated when
determining the recommended data content. Although most – institutions already have
established documentation practices, the highly recommend that healthcare organizations
evaluate the data content. Standardizing data content is a key component of an EHR implementation
and will help HIM professional effectively manage health information for quality patient care. There
are four main sources for documentation guidelines : Facility – specific standards, licensure
requirements, government reimbursement standards, and accreditation standards.
ACO is local health care organization that make changes to cost and quality problems that
Impact on private payers. Improving quality health care is a very serious issue in this world today.
Because of the broad policy of agreement on an evidence base regarding, the need for provider
The Essay on Making and Adoption of Health Data Standards
The Making and Adoption of Health Data Standards Health Data Standards (HDS) are a key part of the construction of a National Health Information Network (NHIN). Having these standards will increase interoperability of various groups and organizations, improve safety, lower costs, and enable providers in all aspects of healthcare to access the same patient medical information easily and ...
payment and delivery system that reforms financial incentives for providers to work together to bend
the cost and improvement of quality, ACO is one of the few attempts to move ahead to achieve these
proposals.
HEALTH RECORD DOCUMENTATION STANDARDS 8
References
Centers for Medicare and Medicaid Services, “Medicare Accountable Care Organizations
Shared Saving Program—New Section 1899 of Title XVIII: Preliminary
Devers, Kelly and Robert Berenson, “Can Accountable Care Organizations Improve the
Value of Health Care by Solving the Cost and Quality Quandaries? (Washington, DC:
Urban Institute, October 2009).
AHIMA. “Update : Guidelines for Defining the Legal Health Record for Disclosure Purpose.
“Journal of AHIMA 76, no.8 (2005) : 64 A-G.
AHIMA. “The Legal Process and Electronic Health Records. “Journal of AHIMA 76, no. 9
(2005) : 96 A-C.
ASTM International. Standard Specification for Healthcare Document Formats : E2184 – 02.
www.astm.org
Huffman, Edna K. Health Information Management. 10th ed. Benwyn IL. Physicians
Record Company, 1994.
Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K. “Data Content for EHR Documentation.”
Journal of AHIMA 78, no.7 (July 2007) : 73 – 76.
Quinsey, Carol A. “Foundational Concepts of the Legal EHR.” Journal of AHIMA 78, no. 1
(January 2007) : 56 – 57.
Saskatoon, Saskatchewan, Health Record Documentation Standards, Saskatoon Health Region,
May 2003 www.saskatoonhealthregion.ca/…APPA.pdf
