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NURS IM3001A Module 3 Response to Patient Regarding Changes to Electronic Health Record (EHR) Paper Example
NURS IM3001A Module 3 Pre-Assessment Response to Patient Regarding Changes to Electronic Health Record (EHR) Assignment
NURS IM3001A Module 3 Response to Patient Regarding Changes to Electronic Health Record (EHR) Assignment Brief
Course: NURS 3110A – Information Management and Patient Care Technology
Assignment Title: IM3001A Module 3 Pre-Assessment Response to Patient Regarding Changes to Electronic Health Record (EHR) Assignment
Assignment Instructions Overview
The purpose of the Module 3 Pre-Assessment Assignment is to prepare students for their final Competency Assessment by applying their understanding of nursing informatics in a practical scenario. This pre-assessment focuses on a common issue in healthcare: addressing inaccuracies in a patient’s Electronic Health Record (EHR). Students will use this assignment to demonstrate their knowledge of EHR management, including the legal and ethical considerations involved in making corrections to health records.
Understanding Assignment Objectives
The primary objective of this assignment is to help students develop a comprehensive understanding of the procedures and regulations governing the modification of EHRs. Students will learn how to communicate effectively with patients about the constraints and protocols associated with EHR amendments, ensuring that patients are informed about their rights and the steps required to correct their health information.
The Student’s Role
In this scenario, students are placed in the role of a healthcare provider who must respond to a patient’s request to correct inaccurate information in their EHR. The student’s response should:
- Clearly explain to the patient why direct changes to the EHR are not immediately possible by the patient or provider without following established procedures.
- Outline the formal amendment process that must be followed to ensure that any corrections to the EHR are handled legally and ethically.
- Reference relevant legal requirements, such as those stipulated by the Health Insurance Portability and Accountability Act (HIPAA), to support their explanation.
Competencies Measured
This assignment measures several key competencies, including:
- Knowledge of Nursing Informatics: Understanding the role of informatics in healthcare and how EHRs are managed to maintain data integrity and patient safety.
- Legal and Ethical Understanding: Familiarity with laws and ethical guidelines that govern the handling of patient health information, particularly regarding amendments and corrections.
- Communication Skills: Ability to communicate complex information clearly and empathetically to patients, ensuring they understand the reasons behind healthcare procedures and their rights.
- Problem-Solving Skills: Developing practical solutions to common issues in healthcare informatics, such as handling requests for EHR corrections.
You Can Also Check Other Related Assessments for the NURS 3110A – Information Management and Patient Care Technology Course:
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NURS IM3001A Module 3 Response to Patient Regarding Changes to Electronic Health Record (EHR) Paper Example
Explanation to the Patient:
In response to your request to make changes to your Electronic Health Record (EHR), I understand your concerns and the importance of having accurate information in your health records. However, it is important to follow a structured process to ensure the integrity and accuracy of the EHR system.
First, I must inform you that neither you nor I have the authority to directly alter the EHR. This restriction exists to maintain the reliability and trustworthiness of the information stored within the healthcare system. The information in your EHR is protected and regulated by strict guidelines and laws to ensure it accurately reflects your medical history and current health status (HealthIT.gov, 2018).
If you have identified incorrect or outdated information in your EHR, the appropriate course of action is to notify your healthcare provider. You should detail the inaccuracies you have found and provide any supporting documentation if available. Your healthcare provider will then review the information and, if necessary, initiate a formal amendment process to correct the errors (McBride et al., 2018).
Reasons for the Response:
Legal and Ethical Guidelines
The integrity of EHRs is protected by legal frameworks such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States. HIPAA sets standards for the protection of health information and governs how patient information should be handled to ensure confidentiality, accuracy, and security. Unauthorized alterations to the EHR can lead to serious legal consequences and compromise the trustworthiness of the healthcare system (Office for Civil Rights, 2013).
Ensuring Patient Safety
Accurate and up-to-date health records are crucial for delivering effective healthcare. Inaccurate information can mislead healthcare providers, potentially resulting in inappropriate treatments, medication errors, or misdiagnoses. Following the formal amendment process ensures that any corrections made to the EHR are verified and documented appropriately, thereby maintaining the safety and well-being of the patient (Bowman, 2013).
Maintaining Data Integrity
EHR systems are designed to create a reliable and permanent record of a patient’s medical history. Allowing unauthorized changes to these records would undermine their integrity and could lead to a breakdown in the continuity of care. The established protocols for amending EHRs are in place to preserve the accuracy and reliability of the information, ensuring that all modifications are traceable and accountable (HealthIT.gov, 2018).
Legal Requirements and Processes
Under HIPAA, patients have the right to request corrections to their health information. This request must be made in writing, and the healthcare provider must respond within a designated timeframe. The provider may deny the request if they believe the information is accurate and complete, but they must provide a written explanation for the denial. If the request is accepted, the provider will amend the record and inform the patient of the correction. This formal process ensures transparency and accountability in maintaining EHRs (Office for Civil Rights, 2013).
Ethical Considerations
From an ethical standpoint, healthcare providers have a duty to uphold the principles of beneficence and non-maleficence, ensuring that actions taken are in the best interest of the patient and do no harm. Ensuring the accuracy of health records aligns with these principles, as it supports the delivery of high-quality care and protects the patient from potential harm due to erroneous information (McBride et al., 2018).
Conclusion
In summary, while the process of correcting errors in your EHR may seem cumbersome, it is designed to protect your health and ensure the accuracy and integrity of your medical information. I encourage you to discuss the inaccuracies with your healthcare provider, who can guide you through the formal amendment process. This approach ensures that any corrections made are appropriately documented and verified, maintaining the trust and reliability of the healthcare system.
References
Bowman, S. (2013). Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in Health Information Management, 10(Fall). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797550/
HealthIT.gov. (2018). The benefits of electronic health records (EHRs). Retrieved from https://www.healthit.gov/topic/health-it-basics/benefits-ehrs
McBride, S., Tietze, M., Robichaux, C., & Stokes, L. (2018). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism. Springer Publishing Company.
Office for Civil Rights (OCR). (2013). Summary of the HIPAA privacy rule. U.S. Department of Health and Human Services. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
Detailed Assessment Instructions for the NURS IM3001A Module 3 Response to Patient Regarding Changes to Electronic Health Record (EHR) Assignment
IM3001A Module 3 Pre-Assessment Assignment
IM3001A Module 3 Pre-Assessment (PDF)
Module Pre-Assessments are your opportunity to practice applying module content before final submission of your Competency Assessment. For your final Competency Assessment, you will address scenarios related to the importance of nursing informatics in healthcare.
For your Module 3 Pre-Assessment, respond to the following prompts. These prompts match those in your final Assessment. Be sure to support your responses with evidence from scholarly literature.
Prompts:
Scenario:
A patient approaches you after her consultation with her physician. Her physician had reviewed her electronic health record with her during the consultation. The patient realized that some of the information in her EHR was incorrect. The patient asks you to make changes to this information. Is this possible? Why or why not? Write a 1-page response that includes the following:
- Describe what you would tell the patient in this scenario regarding making changes to her electronic health record (EHR).
- Explain your reasons for responding to the patient in the way you describe.
- Be sure to reference any legal requirements related to EHRs.
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