I’m working on a health & medical writing question and need a sample draft to help me understand better.A – Information Integrity and QualityundefinedB – Information Access, Security, and ConfidentialityundefinedC – Data Design and CaptureundefinedD – Content and Records ManagementundefinedE – Information Analysis and Use undefinedF – Information Governanceundefined Scenario Category
The nurse connects the patient’s home blood pressure monitor to the EHR to import the data but associates it with the incorrect patient so the data is attributed to the wrong patient. A Policies for information management do not meet the needs of the patient care staff in the clinics because only the IT staff were involved in developing them. The EHR system was unavailable because of a power outage for 5 hours and the ED staff were unclear on how to register or document information on patients who needed to be admitted during this time.
An auditor asked to review medical records from two years ago and it was discovered that they had been destroyed even though legally the hospital was required to have retained them for at least another 5 years. A patient comes in unconscious to the ED and the provider treating her is unsure about her allergies as it does not show any allergies in the structured Allergy section of the EHR but he found a typewritten freeform note from one of her clinic visits stating she had an allergy to penicillin. The organization’s EHR contains a large percentage of unstructured text and the organization would like to explore purchasing Natural Language Processing software, which will search unstructured text to find data that can be identified and become structured for reporting purposes. Any doctor in the organization can contact the analytics department with data requests for their research, they do not need to explain how the information will be used or what their basis is for the request. The Chief of Surgery signed a contract to purchase a new add-on software to the organization’s EHR that he saw a demo of at a conference he just attended.It has been developed by a start-up medical software company.It interfaces with the organization’s EHR, and utilizes the Cloud to send patient symptoms and comorbidities to multiple databases to assess surgical risk.
He is not sure if the interface includes protected health information.He contacts the IT EHR manager and wants her to implement this and connect it to the EHR as soon as possible so his department can start using it. It has been determined that when providers electronically sign their notes in the EHR, it is only marking their name and the date signed, but not the time that the note was signed. The organization would like to do more quality reporting to find areas for improvement, but the CEO is concerned that the data is not sufficient or reliable enough that the results can be depended upon to make decisions. There are no policies or procedures in place in the organization for any of the above scenarios and it is unclear who should be involved in starting this process.
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