Improving Patient Health Through Standardized Representations of Health Information

1.1 Identify legislation and codes of practice that relate to handling information in health and socail care

UHDDS – Uniform Hospital Discharge Data Set collects data elements from only inpatient health records.

On the basis of current law all the health information about patient should be keep safely.

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

Quality patient care requires the communication of relevant information between health professionals and/or health systems. Healthcare professionals who regularly work with patients and their confidential medical records should contribute to the development of standards, policies, and laws that protect patient privacy and the confidentiality of health records/information.

In this task I will be describing how health and safety legislation, policies and procedures promotes the safety of individuals in a Hospital. Quality care is an important issue for both health care workers and their partners. Government continue to work on implementing staffing law that will upgrade the medical systems. Hospitals are required to provide security for patients and staff. Mechanical equipment, housekeeping, administrative and food staff play important roles in preventing all environmental hazards. Safety concerns surrounding these hazards include injury, illness, disease exposure, disaster

At the level of the external environment, health information management in itself, as well as the people employed in the adjacent departments, are continually impacted by new standards, regulations and initiatives. The scope of these standards, regulations and initiatives is usually that of increasing the efficiency and quality within the health care system, "o provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare" (U.S. Department of Health & Human Services).

Health Information Exchange (HIE) supports both transferring and sharing of health related information that is usually stored in multiple organizations, while maintaining the context and integrity of the information being exchanged (HIE, 2014). The goal of health information exchange is to expedite access to and retrieve clinical data to provide safe efficient, effective, equitable, timelier patient-centered care (HIE, 2014). HIE “provides access and retrieval of patient information to authorized users in order to provide safe, efficient, effective, and timely patient care” (HIE, 2014).

The Health Information Exchange has proven to be convenient and beneficial in essence of improving patient and health professionals’ ability to access patient medical histories and records by providing quicker, more reliable access. There have been some challenges recognized with the implementation of the health information exchange. While speeding up the process of retrieval of sensitive medical records has been a blessing, the process of electronic delivery of medical records has also been seen by some as risky. The electronic health information exchange allows health care providers to release vital private patient healthcare information via

Establishing standards for vocabularies promote data quality within health information systems. Scholarly works support this principle within the Health Information Management profession. The following articles support data quality, standardization, and interoperability as critical components of health information management and exchange. The goal of true exchange will include data sharing of critical information across the care continuum, often across disparate systems.

Every day in the health care field, professional have to choose the most effective communication method when communicating to other professionals, patients, patient families, and the general public. Different circumstances have very specific methods of communication that need to be utilized for communication to be effective. Furthermore, in the health care field the regulations of HIPAA have to be considered to ensure that certain information is being protected as well as identity of people pertaining to the health scenarios. Further will be discussed the methods of communicating in the health care field, the advantages

‘Clear and complete communication between health care providers is a prerequisite for safe patient management. Which is a major priority of the Joint Commission's 2008 National Patient Safety Goals and long-term care (LCT). (Commission, 2008)

PhRMA supports the development of high quality information about patients’ medical treatment options. Empowering patients and physicians with high quality information will help ensure that our health system efficiently delivers the best possible results for all patient.

There are many types of data collected, such as, Demographic, financial, socioeconomic, and clinical data are collected from patients so that the healthcare providers of services to the patient are able to assess the history of whatever disease the patients is suffering from and how is to be treated. Data collection in the facility is well organized in a way that promotes shared assessment, treatment and communication. Nurses and front row staffs collects raw data’s from the patient, and. The Heath Information Manager and team are the facility are responsible in analyzing and presenting the data collected in a meaning and easily understandable way to served the specific purposes for which it was collected. Examples of such data are, patient’s name, height, weight, gender, allergies, and third party

Within the Electronic Health Record program, the nurse has access to evidence-based practice tools that can assist the nurse in making decisions regarding the patients plan of care (Linder, J., Bates, D., Middleton, B., & Stanfford, R., 2007). The most important feature of the Electronic Health Record is the ability to instantly provide real-time patient-centered data to all authorized providers (HIT, 2013). The Electronic Health Record is real-time, providing nurses with the most up to the moment patient information the significance of this feature can be explained in the following example. For example, if a patient is in surgery, the patient's health record is available to the circulating nurse in the Operating Room, the Post Anesthesia Care Unit nurse and can be shared with the unit staff nurse the patient will be transferred to after recovering in the Post Anesthesia Care Unit. This is of particular importance because having access to the patient's chart, allows the nurses at each phase on the patient's care the ability to prepare supplies, gather necessary equipment and arrange for supplementary staff. Evidence-based practice suggests appropriate planning is a key factor in promoting positive, cost efficient patient outcomes (Anderson, 2012). In the profession of nursing when time is of the essence, and time loss can mean loss of a life, this is a feature that is very