The Nightingale Hospital Next Joint Commission Inspection.

Records contain very sensitive personal information; they are regarded as legal documents and are a legal requirement to be kept. All information written in files should always be clear, useful and relevant. Do not include anything irrelevant or opinions that are not backed up by facts. Only the patient whose notes you are writing in should be written about and all entries should be clear, factual and true.

Information Management has to do with capturing information, efficient planning, organizing and evaluating the information to interpret for an organization to make well informed decisions. (Hinton, 2006) The main reason organizations depend on information is to improve its overall management in

Information management is a conscious process that needs to be planned. Having regular updates of the business is information gathered and this assists in any decision making. This is to be used by the business and is most useful at the starting point of the decision making process. The information gathered should be used at all levels of the business not just at senior management positions.

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

Updating and maintaining the accuracy of records and reports is vitally important for any care setting. The information in records or reports could be about an individual who is being cared for in our workplace, a relative or friend, or it could be about the organisation itself, about of for someone who works there, or for administrative purposes. The information could come to us in different ways: verbally- in a conversation or on the phone; on paper- in a letter, an individual’s health record, instructions from a health

The hospital’s plan for information management encompasses the full spectrum of data generated and used by the organization in all various departments from housekeeping, laundry services, imaging, and pharmacy through to nursing. In order to provide cost-effective quality services, information must be accurate and communication of the information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis.

Medical record keeping has a robust history of promoting patient care. The patient’s need for optimal

responsibilities and duties in maintaining the records to meet needs of health care stakeholders. Abuse

Information Management is the collection and management of information from one or more sources and the distribution of that information to one or more audiences.

The American Health Information Management Association is a body of health information professionals that majorly concerns itself with the improvement of the quality of medical records (Harman 104). These

Records management is defined as the systematic life-cycle management of records that includes identification, collection, classification, storage, retrieval, and, eventually, disposition (Records Managment: Buisness Definition, 2010). There are many elements which fall under the management of patient records including but not limiting to; patient data maintenance, identifying, classifying, and storing records, and identifying information requiring capture. Questions six thru twelve of the interview assignment from week four discuss similarities and differences between the circulation, tracking and security measures for

Ultimately, the goal of health information is to create a bridge among healthcare organizations or patients that helps them exchange information. For this purpose, the health informatics

Information management (IM) is the collection and management of information from one or more sources and the distribution of that information to one or more audiences; is also particularly critical to businesses that work in conjunction with other businesses, so the two must share information with, or transfer information to, each other. In addition, businesses with more than one department or unit can use the MIS to compile information in one central location, thereby preventing information loss.

Information in healthcare needs to be meticulous, detailed, appropriate and up to date. It is critical the information we obtain and share on patients is accurate and easily available in an instant. The growth of the information technology industry has grown dramatically in the last 10-15 years, and the healthcare industry recognizes its importance. The mandate set forth in 2004 by the Office of the National