Electronic Health Records

This week’s live conference was very informative. It is important to understand the features and functions of the electronic health record. The health record has several users, who can either enter pertinent information or review and extract data for medical or business purposes. Some users of the health record platform include; physicians, nurses, therapist, imaging technologist,,quality review managers,data analyst, compliance and quality managers. There are three major section in the health record that was mentioned in the live conference. The first section mentioned was the Business information, which includes but not limited to information about the patient’s insurance, payments, and claims, routine patient identification such as the patient’s name, age, sex, date of birth,

Health records contain source document and other business data that assist in the process of coding. Source document or clinical data include initial history and physical information, physician notes, diagnoses, procedure reports, discharge summary and results of tests such as laboratory work, radiology imaging studies, and operations. There are other data that are collected but cannot be used for coding such as, transfer records, nursing notes and admission data. The history and the physical report is usually dictated by the attending physician and then transcribed by medical transcriptionists. This report is an important form that uncovers the chief complaint of the patient, history of the present illness, and personal, family, and social history. This contains subjective data collected from the patient to begin the process of diagnosis by the physician. The physical examination includes a system-by-system physical examination by the provider to collect objective data on the patient’s condition. The live conference also highlighted some important health record