Data Mapping and Its Impact on Data Integrity

Data Mapping and Its Impact on Data Integrity

Learning Outcome: Construct information architectural models

Additional Reading:  Data Mapping and Its Impact on Data Integrity.  AHIMA. 2013  http://bok.ahima.org/PdfView?oid=107154

1.   Designation

Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).    For this assignment, you will access an excel file that contains some of the documents or files that are to be reviewed.  See above link for template.  This is not an exhaustive list.  For each element, you will indicate the primary source of the document.  For example, if your institution has an electronic capture of consent forms, then the source would be the EHR documentation system.  But if consent forms are still done via a paper form, then you would indicate that the source is paper.   Examples of the primary sources are given below.  This is not a complete list, so if your institution has a different source for the information, you are free to use that.

Examples of Primary Sources

Paper

CPOE

Nursing documentation system

EHR documentation system

PACS (Picture Archiving and Communication System)

Transcription

Financial System

Administration system

Admitting documentation system

You will also indicate if the document/file is part of the Designated Record Set or the Legal Health Record. Part of the assignment includes formatting the file in a way that is user friendly to the reader.  This may include regrouping some of the items, using shading or borders to help the end user find information, or you may need to add additional columns to capture the information you feel is important (although additional columns are not required).  If your entries do not fit into the template column width, please format so that the entry is wrapped in the cell.

The comment section can be utilized for any clarification you may wish to make.

2.   Retention

In addition, you will research the retention requirements for these documents.  In some areas, there are no specific guidelines.  It is up to the institution to determine the retention period.  If you cannot find a specific time period, either check with your institution, or use your best judgement and indicate your reasoning in the comment section.

Resources

State Medical Record Laws.  Table A-7. HealthIT.   https://www.healthit.gov/sites/default/files/appa7-1.pdf

Retention and Destruction of Health Information.  AHIMA.  2013.  (http://library.ahima.org/PB/RetentionDestruction#.V9LcAzW8JsU

3.   Reflection

Write a two -three paragraph reflection on how this exercise (identifying the source and type of document) will help when mapping the components and structuring an EHR.

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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument