Documentation for Medical Records - Essay Example

Health Care Services How the ONC-Coordinated Federal Health Information Technology Strategic Plan is being implemented at your place of employment The aspect of health care has witnessed different elements of advancement and development with the inclusion of technological development and the kinds of new technology that have been embraced by the health sector have received mixed reactions from the public and the stakeholders in the sector. Scientific knowledge has been expanding rapidly over time now and has been incorporated in the provision of health services by various departments within the sector and to perform various functions. The benefits that have been facilitated by these technological developments have, however, been accompanied by different levels of dilemma from the patients as well as from the practitioners in the system. Technology, through scientific advances has created many questions in regards to the definition of life and death and the particular issues affection either of the two. The kinds of dilemmas include such questions such as the kind of situations that may want technological intervention in the provision of healthcare, who decides the right time to intervene with the use of technology and when to withdraw? Other problems that have been experienced in some cases are when the nurses get to apply more time handling the technological equipment as compared to the time used to handle patients. (Brownson, 2009) Some of the different ways in which technology has been applied in the health sector include diagnostic procedures, gene therapy, gene diagnosis, surgical techniques, surgical equipment, surgical machines and medications. The new interventions in technology have alleviated suffering, enhanced the value of life as well as saving lives. At my place of employment, the planned strategy brought by new technology is being applied to correct deformities, help those with difficulty in breathing, restart arrested hearts, replace malfunctioning vital organs and in the elimination of disease through the use of surgery. The quality of life has been boosted with the development of technology because different illnesses can now be controlled by critical use of technology. (Brownson, 2009) The other element that shows the use of technology is when there is a need to intervene in a matter of living and dying. Problems have been encountered in regards to determining when to intervene through the use or the withdrawal of life support systems of treatment. The issue about when to intervene in this case is based on ethics and beliefs of the patients involved. The Patient Self-Determination Act was implemented to see through the process of decision making when patients have to undergo a medical procedure especially in the cases of adults to seek their consent. The nurses have often been expected to support the patients in decision making and this is one way through which Coordinated Federal Health Information Technology Strategic Plan is being implemented to ensure that no rights are interfered with in any way. Some clinicians have often downplayed the recommendations of the PSDA because of the belief that they know exactly what is best for the admitted patients and so they decide for them. Doing so goes against the law and should be prosecuted in the case that a medical practitioner goes against the recommendations. (Brownson, 2009) 2. Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations An individual may be considered as vulnerable if their access to healthcare has experienced a problem because of underlying reasons such as financial circumstances, age, developmental or functional status or place of residence and the ability to communicate efficiently. Some other factors that characterize vulnerability are personal characteristics like ethnicity, sex and race and these features have also contributed to the fact that some citizens do not get similar services as everyone else. Social policies on health care have stated that the consumers have the rights to respectful and considerate care that is free of discrimination. The special needs of the vulnerable populations have to be checked through the critical use of design systems in the elements of healthcare delivery, payment and quality measurement. (Burkhardt, 2013) Some of the ways to do this is through the evaluation and development of measures regarding healthcare quality as well as other methods of measurement for the vulnerable population should be given the relevant support. An example of the ethical framework is in the case whereby a barrier to communication is experienced. Communication difficulties in this case may be seen in the level of development or education of the patient, cultural or language differences, mental of physical disabilities or health condition that may present the patient with difficulties expressing their problems or their preferred systems of treatment, provision of informed consent for medical procedures or in making known what is acceptable according to the ethics that he/she transcribes to. The social policies have placed some preferred treatment services for such cases and have placed mechanisms in place to ensure a considerable reduction in communication barriers to ensure that accurate data is captured from the patients. (Burkhardt, 2013). 3. Examine patient confidentiality in relation to EHRs and PHRs ERC is seen as an idea that uses electronic devices to store data containing patient records that can be accessed easily by patients who routinely view their medical records available electronically containing diagnoses and other components of health documentation. Patient confidentiality should be considered at all times when handling such information and must be protected at all times. The information about the patient should only be unveiled to a second party by the patients consent but the physicians are allowed by federal law to access the records for treatment purposes or for payment and the patient too has the right to access the records at convenient times. Usernames and passwords have been installed in the computer record programs to ensure that the records are safe whereby some medical institutions use specific forms of identification before gaining access like the patient’s fingerprints or facial recognition. User privileges may apply when one needs that information to fulfill the responsibility and have to provide accountability for the information that they handled. If ones uses patient information and records without their permission it is considered illegal and should be prosecuted by law because the information may be used to slander the personality of the patient in public by malicious individuals and so the information should stay confidential at all times. (Odom, 2009)  References Brownson, R. (2009) Understanding evidence-based public health policy. Am J Public Health. Burkhardt, M. (2013) Ethics and Issues in Contemporary Nursing, 4th ed. Cengage Textbook. Kindle Edition. Odom, W. (2009) Documentation for Medical Records. Chicago: American Health Information Management Association. Read More