Reference no: EM133564340

Heatlh Record Content and Documentation

For each of the following questions, u must justify ur answers and use references (preferably your textbook and peer-reviewed articles) to support them. Websites, such as Wikipedia, newsletters, or blogs, are not acceptable.

The following case is from the textbook with some modifications.

John Smith, a 50-year-old with a history of Diabetes Mellitus and cardiac disorders, has been admitted to the Seaside Hospital two times. His first admission was because of uncontrolled high blood sugar, and the second time was due to chest pain. After both admissions, he received complete care and was discharged home with stable health status.

Yesterday, Mr. Smith was referred to the Seaside Hospital for elective surgery to remove a benign skin lesion. During the admission process, the registration clerk found 20 John Smiths in the Electronic Master Patient Index (EMPI). There were three John Smiths in the system with the same date of birth; one had a full address, one had a missing street number, and one with no address. The John Smith full address lived at 121 Greenwoods St, Atlanta, GA, and our John Smith lives at 211 Greenwoods St, Atlanta GA. Both street numbers existed based on the clerk's research. Since the registration was extremely behind schedule and many patients were in the waiting room, the clerk decided to add Mr. Smith to the EMPI as a new patient and then remove the duplication later if there was any.

During the course of preparation for surgery, the nurse completed the history and physical, which indicated the previous hospitalizations, but the nurse was not able to retrieve the information about previous hospital admissions, including the chief complaint, diagnoses, treatment, and the conclusion at the termination of care. After Mr. Smith spent four hours in the waiting room and Dermatology Department, the nurse and surgeon had to cancel the procedure and reschedule the treatment.

Discussion Questions:

Identify the problems in the process.
Indicate and discuss the Health Information Management issues.
u must discuss the management of health records content.
What sections of incomplete health record control were missing in this system? Discuss and justify ur answer.
What criteria of adequacy of documentation are missing? Explain each.
What information could the treatment team use from the previous admissions to reduce possible risks of this operation?
What are the consequences of such a mistake in the real world?