Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:The Role of Medical Records in U.S. Health Care
Slide content:The Health Record as Tool for Patient Safety Providing care based on a full understanding of a patients current and past conditions is a key element of safe care Information in the health record is monitored for accuracy and completeness The health record is used to manage risk and improve care 6
Slide notes:Safe patient care necessitates that all care providers have a complete and accurate picture of the patients current and past medical conditions. From admission to discharge, whether in an acute care facility, outpatient setting, long-term care, or any other health care system, the information that is documented in the health record is carefully monitored for accuracy and completeness. After the patient leaves a health care system, the health information management department, or HIMD, continues to assess the completeness of the electronic record. In an electronic health record that includes scanned paper documents, the quality of the scanning process and filing of the documents in the correct area of the record will affect future use of the scanned information. When an error or incident occurs, an incident report is generated and the risk management department reviews and addresses the incident. Health care organizations provide ongoing education to care providers regarding best practices in clinical documentation. Education is also provided regarding areas of identified clinical documentation deficiencies or inaccuracies so that they can be avoided. With improved documentation quality, patient safety and health care quality also improve. 6