Health Records Documentatio and Storage

Health Records Documentation and Storage
Student’s Name
Institutional Affiliation
Abstract
The remarkable increase in activities associated with adopting personal health records systems for consumers and patients in health care organizations reiterates the massive role that such records play in ensuring that such organizations offer exceptional health care to consumers. As a not-for-profit organization tasked with accrediting and certifying the commitment of organizations to specific performance standards, The Joint Commission has identified history and physical (H&P) guidelines that health organizations have to meet. The Commission requires organizations to document all care, treatment, and services offered to patients in the Electronic Health Record (HER). Similarly, the State of Texas developed a set of guidelines and standards that health care organizations have to follow while entering and managing clinical records. Both measures require organizations to ensure that clinical records are complete, accurately documented, readily accessible and systematically organized for easy retrieval by health care practitioners.
Keywords: History and Physical (H&P), Electronic Health Records (HER)
The contemporary health care sector has witnessed an upsurge in the need for accurate and readily accessible patient data to guide clinical decision making. This has elicited the need for health care organizations to require all practitioners to enter patient data into clinical records as soon as the patient visits the facility to guide the diagnosis and determination of the care approach (Tang et al.

, 2006). Both TJC and Texas standards are similar in that they require the timely entering of patient data into the system, ensure that the records meet the regulatory requirements associated with documenting health records and require practitioners to authenticate the records. However, while the Joint Commission does not have any provision for the records to be validated before surgery or any other procedure that requires anesthesia services, the Texas standards require health care practitioners to authenticate all records.
As noted by Tang et al. (2006), it is necessary for health care organizations to document the patient’s social and personal history to ensure that practitioners have access to a vast array of relevant patient information that could guide the treatment and care model. The Joint Commission requires all organizations to enter patient information into the Electronic Health Record (EHR) within 30 days after admitting the patient into the facility (HPM, 2018). It is also essential to document the chief complaint since it explains the reason behind the patient’s decision to seek medical care thus guiding the diagnosis, treatment, and care process. In line with the need to safeguard the safety, security, and integrity of patient information, both sets of standards require health care organizations to ensure and maintain the integrity of confidential patient information.
References
HPM. (2011). State Regulations Pertaining to Clinical Records. Retrieved from: http://www.hpm.umn.edu/nhregsplus/NH%20Regs%20by%20Topic/NH%20Regs%20Topic%20Pdfs/Clinical%20Records/category-administration-clinical%20records-final.pdfTang, P. C., Ash, J. S., Bates, D. W., Overhage, J. M., & Sands, D. Z. (2006). Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. Journal of the American Medical Informatics Association, 13(2), 121-126.