Content of the Health Record

Primary Discussion Response is due by Wednesday (11:59:59pm Central), Peer Responses are due by Sunday (11:59:59pm Central).

Primary Task Response: Within the Discussion Board area, write 400–600 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.

Step 1: In preparation for the electronic health record (EHR) implementation, you are assisting the information technology (IT) and admissions departments in creating a data dictionary for the master patient index (MPI). Discuss the following:

• Describe 3 data elements that are contained in the MPI.
• State what is acceptable data for each element.
  • For example, the element of marital status must allow the terms single,married, widowed, and so forth.
• Do the elements that you have selected meet the Health Information Technology for Economic and Clinical Health (HITECH) Act’s 3 stages of meaningful use?
• Discuss how this relates to the patient access and billing functions within a health care organization.

Step 2: While working with the IT and clinical departments, you are assisting them in creating a drop-down menu for the histories that are recorded in the patient record. You will be responsible for making sure that 2 types of histories include all of the elements required. Choose 2 of the following histories, and list the elements that must be included as part of that history:

• Past medical history
• Chief complaint
• Past surgical history
• Past family history
• Social history

Be sure to support your information by citing at least 2 references using APA format.