Update with Complete Solution
C803
ID: 011324449
BRITTANY SHORTER
A:..CHARACTERISTICS
Data..is..everywhere...Anyone..who..uses..data..has..three..major..things..to..worry..about:..how.
.is..the..data..stored,..how..can..it..be..accessed,..and..how..can..it..be..amended...In..healthcare,..there..ar
e..three..major..ways..that..personal..health..information..is..stored...A..record..can..be..stored..on..paper
,..on..both..paper..and..electronically..or..hybrid,..or..all..electronic...For..any..type..of..record,..each..patie
nt..receives..a..medical..record..number..(MRN)...This..is..a..unique..number..that..can..be..used..to..loca
te..and..retrieve..a..specific..patient’s..health..information.
For..paper..records,..each..patient..was..given..a..manilla..folder...Each..folder..was..typically..store
d..on..shelves..in..a..record..room..within..the..facility...This..also..means..that..as..the..records..grow,..th
ey..require..more..space..which..could..be..expensive..and..difficult.. . Each..folder..contained..patient..sp
ecific..documentation..related..to..care..received..from..the..physician..or..physicians...The..good..thing
..about..paper..records..is..they..are..easily..accessible..by..the..staff...Paper..records..are..also..easy..to..c
arry..if..the..patient..wanted..to..transfer..to..a..new..doctor..or..needed..to..see..a..specialist...However,..p
aper..records..were..generally..not..backed..up...It..is..also..impossible..for..more..than..one..physician..t
o..edit..a..single..piece..of..paper..for..a..medical..record..at..the..same..time...A..patient..chart..could..onl
y..be..used..one..physician..at..a..time...Because..everyone..has..a..different..writing..style,..paper..records..c
ould..also..be..seen..as..difficult..to..read..if..someone..else..needed..to..read..a..report.
Hybrids..records..exist..on..both..paper..and..electronically...This..type..of..record..is..usually..se
, en..when..a..company..has..made..the..decision..to..transfer..to..an..electronic..health..record..versus..a..p
aper..record.. . Because..paper..is..still..involved,..the..same..challenges..still..apply..as..far..as..storage..and..
access...Accessibility..is..slightly..easier..due..to..records..being..electronic...Updating..and..amending.
.records..is..also..easier..with..an..EHR..since..they..are..electronically...Paper..records..would..also..have..to..
be..amended..every..time..the..EHR..is..amended...Th
A1:DATA..TYPES..EXAMPLES
A..primary..date..source..can..include..clinical,..administrative,..and..operational..data..(Johns,.
.2015)...Clinical..data..can..include..documents..and..reports..that..are..generated..by..humans..and..machine
s..(Johns,..2015)...Documents..created..by..humans..can..include..the..operative..report,..any..patient..his
tory..that..has..been..shared..with..medical..staff,..or..physical..exam..reports...All..these..things..become
..part..of..the..patient’s..paper..health..record..or..electronic..health..record...In..today’s..healthcare..syst
em,..most..charting..is..putting..into..a..computer..that..is..conveniently..located..at..the..patient’s..bedsi
de...This..is..called..the..point-..of-
care..(POC)..charting..system..(Johns,..2015)...This..type..of..charting..is..typically..done..at..the..time..a
ny..care..is..rendered..to..the..patient...A..POC..charting..system..uses..structured..data..entry..technique
s..such..as..checklists,..templates,..and..drop-
down..menus..to..input..information...Patient..history,..clinical..notes,..and..physical..exams..all..use..PO
C...Clinical..data..can..also..be..entered..using..computerized..provider..order..entry..or..CPOE..(Johns,..
2015).. . Because..CPOE..uses..more..than..structured..data..entry,..physicians..and..other..providers..ca
n..enter..medication,..treatment,..and..other..patient..care..orders...This..system..allows..physicians..to..
be..alerted..if..there..are..medications..that..have..been..prescribed..and..have..contraindications..to..oth
er..medications.
Administrative..and..operational..data..can..be..a..primary..data..source..as..well...Administrati
ve..and..operational..data..is..any..data..that..deals..with..the..operations..of..the..organizations..such..as..fina
ncial..management,..human..resource..management,..materials..management..and..facilities..manage