Overview
Every EHR contains forms used for different purposes. This journal assignment is meant to help you think about the different forms and documentation. This will be something to consider as you complete your final project for the course.
To complete this journal assignment, think about your experience completing EHR Go Activities and your reading of Chapter 3 in the textbook. You will complete a Data Collection Form, which is linked in the What to Submit section, using the Health Record, which is linked in the Supporting Materials section below.
Prompt
In a journal assignment, complete the following critical elements:
- Summarize the different types of health records (paper versus electronic versus hybrid) and how they are used in healthcare.
- Explain how data can be used in patient care.
- Summarize five different forms or templates found in the health record, and identify the key elements collected on each of the different forms, including the purpose of each form.
- Explain how the forms and structure of a paper record differ from the templates and structure of an EHR.
- Explain why there are different rules and standards that govern the content, storage, and maintenance of health records, such as TJC, state licensing, and the Medicare Conditions of Participation.
- Demonstrate your knowledge of required data elements by completing the attached data collection form using the sample health record.
- Support your answer with relevant resources.
What to Submit
This journal assignment should be at least 3 paragraphs in length. Submit the completed Module Two Journal Inpatient Admission Data Collection Form and a Microsoft Word document with your responses to the prompt items, using double spacing, 12-point Times New Roman font, and one-inch margins. Support your answer with relevant sources and use APA formatting.
Supporting Materials
The following resource supports your work on the assignment:
Reading: Health Record This is a medical record from the Global Care Medical Center for review.