The main purpose attached to records of patients is for the documentation of the care of that given patient. Whether the record format is on paper or on a computer, HIM professionals always strive to suffice the challenges of the requirements of the documentation. Other than documentation of the patient’s information, the medical records serve as tools for collecting, storing and processing the information of the patient. Of importance is that the information should be in an understandable format.
Joint Commission gave an alert concerning subject of abbreviations medical in the medical field, and a year later, the Board of Commissioners of this joint commission approved a safety goal for the patients that required organizations to come up with a list containing abbreviations that are not to be used. In the year 2004, the commission developed its own list containing abbreviations not to be used. Although presently the requirement does not match with the reprogrammed technology systems for the health information it still remains to be considered in future. The organizations considering the introduction or even an upgrade of these systems should at least strive and do away with dangerous acronyms, abbreviations, symbols, as well as dose designations.
The amount of medical tests allowed is determined by the services and materials used up to that point when the suppliers learns the inapplicability of the service. The DMERC (Durable Medical Equipment Regional Carrier) is used in determining the services offered and the amount allowed for the same
All health systems have the responsibility to protect the confidentiality of patients and the information for the patients. The HIPAA Act of 1996 permitted regulations to govern standards of privacy for information on health. The regulations give a specification on the purposes which may require information to be or not to be released without the consent of the patient. So if the information is to be released consultation should be considered before reaching on any rule concerning the same.
Physicians and surgeons of Ontario, Medical Records, Retrieved from http://www.cpso.on.ca/policies/policies/default.aspx?ID=1686
U.S. Department of Health and Human Services, Office for Civil Rights, A health care provider’s guide to the HIPAA privacy rule: pg 1-5, retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/provider_ffg.pdf