Capella HIM4660 2021 November Week 4 Discussion (dq1+dq2) Latest

HIM4660 Information Security, Privacy, and Ethics in Health Care

Week 4 Discussion

DQ1 Poor Documentation Practices

The purpose of the health record is to document patient treatment and continuity of care and provide a place where the health care team records information that can be communicated to one another and used to make health care decisions. It also serves as the legal record for patient care.

In order for the record to fully serve its purpose, good documentation practices are critical. Describe some examples of poor documentation practices in patient records. Explain why these practices are problematic and how they could impact the validity of the legal record. Research and find a documented case to support your perspective on problematic documentation practices with the health record.

Use APA formatting guidelines to properly cite the references used in your post.

Response Guidelines

Respond to at least one other learner who has noted one or more different documentation practices. Explain why you do or don't agree with the explanations. 

Learning Components

This activity will help you achieve the following learning components:

Review professional and ethical codes and legal requirements for HIM.

Determine the proper application of APA formatting requirements and scholarly writing standards.

Understand legal processes related to privacy and security in health care.

Explain HIM processes that protect privacy.

Apply the principles of effective composition.

DQ2 Missing Information

Sandy is a new release of information clerk. She notices that a record due to be released by subpoena is missing some signatures and has several deficiencies. She also discovers that the patient’s last visit and documentation were more than seven years ago. She is not sure what to do about releasing the record or how to find it.

Write a post in which you advise Sandy on what to do with the record based on release-and-retention guidelines.  Explain your advice. Research and provide at least one article or literature resource to support your advice.

Use APA formatting guidelines to properly cite the references used in your post.

Response Guidelines

Respond to the post of at least one learner with contrasting advice.

Learning Components

This activity will help you achieve the following learning components:

Determine the proper application of APA formatting requirements and scholarly writing standards.

Explain HIM processes that protect privacy.

Describe requirements for the use of health information.

Apply the principles of effective composition.