Student Discussion Response.
Please write a response to the following students discussion post.
Week 2 Discussion
Why are paper forms considered as source documents?
Paper forms are considered source documents because its used to enter patient demographics and medical history into their electronic health record. HIPAA instilled these paper forms so that the privacy and confidentiality of the patient is not compromised during the registration process and its easier to add clear and consistent data to the EHR.
Why is it so important to properly develop data collection tools?
Its important to develop data collection tools so its easily accessible, quick and private for the patient. An example of this can be kiosks that are used in the check in process for each visit. When a patient enters a facility, they can check in and update their demographics without having to worry about waiting in line or others in the waiting room hearing their conversation. This also helps the office staff receive “complete, accurate information quickly, so proper development of data collection tools should be an important task in any healthcare setting” (Shanholtzer & Ensign, 2021).
What data is collected and how is it used by the practice?
According to Phreesia, “Patient intake is the process through which healthcare organizations collect demographic, social and clinical data, consent forms, insurance, payments and other key pieces of information from new and returning patients prior to their visit” (2019). All of this data is vital for the practice to properly diagnose and treat a patient. Without these documents, it can create inconsistencies throughout the medical records and result in malpractice. If a person has a history of hypertension in their family, and their vitals from the last three visits reflect rises in blood pressure, its important for the physician to accurately assess the causes, whether it be family history or social history. This cannot be done without proper data collection. Its also important to note that these are legal documents and is “basis for medical decision making” (Shanholtzer & Ensign, 2021).
Shanholtzer, M. B., & Ensign,, A. L. (2021). Integrated Electronic Health Records. McGraw Hill LLC.
What Is Patient Intake? (2019, November 4). Phreesia. https://www.phreesia.com/2019/11/04/blog-what-is-patient-intake/