Patient and Hybrid Record Essay

1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR? The copy/paste function opens the possibility for fraud, medical error and risk for malpractice claims. Fraud could occur when a copy/paste function is used and than an insurance company is billed for the procedure/services 2 or 3 times. When in reality the procedure/service was only completed once. Medical error can occur with the copy/paste function, when a nurse reads a chart made by a doctor who copy/pasted instructions or initiates a procedure that was already completed but the doctor didn’t realize that they copy/pasted it again. Than the nurse completes the procedure again, which can have fatal results. Thus opening the door for malpractice and even criminal suits. Thus the integrity of the whole file would have been compromised by on click of a button. 2. How does copy/paste functionality affect reimbursement? The copy/paste function can affect reimbursement because your insurance could get billed several times for the same procedure that was only completed once. Than your insurance could potentially deny the whole procedure leaving you with the bill and the headache of getting it sorted out. The other side of the coin is that with copy/paste function being used could make it to where someone else’s insurance gets billed if the last copied document is from another’s file than they clicked onto your file and though they highlighted something new but didn’t causing a whole new set of problems. 3. What measures can a hospital take to improve data integrity in their EHR while still achieving their goal of streamlining the documentation process? There needs to be educational training on the functionality of the copy/paste function and when and where it should and should not be used. EHR professionals need to come up with some new software applications that would cut down on the amount of functions that can be implemented into one document without a review by a trained professional. New better software and proper training is the way to go in my opinion. Don’t let staff get lazy and complacent with using the copy/paste function. 1. What impact can a hybrid record have on patient care? The hybrid record could have negative and positive effects on patient care. One negative effect would be that it would take longer to access and put together if a whole file is requested. Another negative would be just where exactly is all of these paper records being kept. A positive effect of the hybrid record is that if the computer system is compromised in some way there would be a paper record. 2. How might the hybrid record change health information management? The hybrid record would change health information management because you would have to have employees to care for all these records, as well as employees for the computer files thus creating more staff and costing more. There would of course have to be training on how to properly handle the hybrid record having thus an effect on the health information management team. Who would have to implement training, schedule personnel off to take the training find yet others to cover for that training. Again costing more money and time. 3. How might a hospital overcome some of the issues created by the hybrid record? To overcome some issues created by the hybrid record you would have to have good education/training in implementation of new data, new software and soft- ware development. Different sections of the hospital should help in the development of software that would be beneficial to the entire hospital or clinic, so that no one section is left out of the decision process, so all need are attempted to be met. Educate not only the HIM staff but the hospital or clinic as a whole so that everyone knows where things are kept and how they are stored.