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Purposes of the Medical Record Communication Legal documentation Communication Legal documentation Reimbursement Education Reimbursement Education Research Auditing/monitoring Research Auditing/monitoring Copyright © 2017, Elsevier Inc. All Rights Reserved. 2 The Shift to Electronic Documentation HITECH established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and value of health care Experts believe that implementing EHRs across the health care delivery system will decrease costs and improve the quality of patient care Difference between EHR and EMR EHR attributes, components, and advantages Copyright © 2017, Elsevier Inc. All Rights Reserved. 3 Interprofessional Communication Within the Medical Record The quality of patient care depends on your ability to communicate with other members of the health care team. When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. Copyright © 2017, Elsevier Inc. All Rights Reserved. 4 Confidentiality Nurses are legally and ethically obligated to keep all patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA requires that disclosure or requests regarding health information be limited to the minimum necessary. Copyright © 2017, Elsevier Inc. All Rights Reserved. 5 Quick Quiz! 1. Information regarding a patient’s health status may not be released to non–health care team members because: A. legal and ethical obligations require health care providers to keep information strictly confidential. B. regulations require health care institutions to document evidence of physical and emotional well-being. C. reimbursement issues related to patient care and procedures may be of concern. D. fragmentation of nursing and medical care procedures may be identified. Copyright © 2017, Elsevier Inc. All Rights Reserved. 6
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