Assignment: Health Records Management Paper

Assignment: Health Records Management Paper

Assignment: Health Records Management Paper

Directions:  Answer in complete sentences, and be sure to use correct English, spelling and grammar. Sources must be cited in APA format. Your response should be four (4) double-spaced pages; refer to the “Assignment Format” page located on the Course Home page for specific format requirements.

A 30-year-old male is admitted to the hospital after an evaluation in the emergency room. After undergoing a series of blood tests and a kidney scan he is diagnosed with HIV/AIDS. After three days of receiving intravenous fluids and antibiotics, he is discharged home in fair condition.

The hospital uses electronic processes to retrieve and store patient records. If you were performing an analysis of this medical record, you would expect to find several documents and clinical evaluations. But before you do, you think about the application of The American Health Information Management Association (AHIMA) and its impact on documentation standards and how these types of cases may impact your career going forward. Explore the history of health information management (HIM) and the AHIMA organization and then answer the questions below.

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1. Make note of the definition for HIM, and review AHIMA’s history, mission, and future predictions. Then, discuss documentation guidelines developed by AHIMA, and how they would apply to the scenario described above.

2. Describe how the recent and future technological changes in health records management has/will impact your chosen career path as a health care professional. You may use the AHIMA website as a resource (www.ahima.org).

Medical Office Management 34 & 35

Anatomy – the study of the structure of an organism

Physiology – the study of the function of an organism

Pathophysiology – the study of diseases and disorders

Homeostasis – a state of balance in which all systems work together to maintain and function cohesively

Element found in the Human body

Aluminum – AL /  Carbon – C  /  Calcium – Ca / Chlorine – Cl / Cobalt – Co / Copper – Cu

Fluorine – F / Hydrogen – H / Iodine – I / Iron- Fe / Manganese – Mn / Magnesium – Mg

Nitrogen – N / Oxygen – O (or O2) / Phosphorus – P / Potassium – K / Sodium – Na 

Sulfur – S / Zinc – Zn

Electrolyte – is molecule that conducts electricity.

Genetics – is the study of the hereditary makeup of animals or plants.

  • Genes are made up of DNA
    • Located in the nucleus of each cell
  • Genetics disorders are considered to be medical conditions that are caused by mutations in a single gene.
    • Mutations are changes in the DNA sequence of a gene
    • Congenital disorder (birth defect) – genetic disorder that is present at birth
      • Albinism (Albino disease) – is a congenital but non-pathological disorder
        • A recessive gene mutation causes hereditary lack of pigment in skin, hair, and eyes. – Patient may complain of photophobia and excessive sun burns
      • Attention-deficit/hyperactivity disorder (ADHD)a disorder that can affect both children and adults. Characterized by the person having difficulty focusing attention and organizing and completing a task.
        • More prevalent in boys than girls (10 times more)
        • Treatment usually requires medication, counseling, developing strategies to deal with the disorders, and dietary restrictions
      • Cleft palate- congenital defect in the roof of the mouth that occurs when the palatine bones of the skull do not close properly

Heredity –  the genetic transmission from parent to child.

Pathogens – Disease producing organisms (are found everywhere including inanimate objects)

Asepsis –  a state of being free from germs, infections, and any microbial life.

Microorganisms (microbes) – organisms that are so small that can be seen only with the aid of a microscope

  • Four main types of microorganisms are generally considered to be bacteria, fungi, protozoa, and viruses.
    • Bacteriology – the study of bacteria
    • Mycology – the study of fungi
    • Protozoology – the study of protozoa
    • Virology – the study of viruses
  • Normal Flora – Microorganisms that are normally found on the skin and in the urinary, gastrointestinal, and respiratory tracts
  • Aerobic – requires oxygen to live
  • Anaerobic – don’t require oxygen to live
  • Multidrug-resistant microorganisms (MDROs) – referred to as super bugs, they don’t respond to traditional medications and treatments and have developed resistant to antimicrobial drugs.
    • Methicillin-resistant Staphylococcus Aureus (MRSA)
    • Vancomycin – resistant Staphylococcus aureus (VRSA)
    • Vancomycin – resistant Enterococci (VRE)
    • Conditions required for bacterial growth
      • Moisture
      • Temperature
      • Oxygen
      • Light

Infections

Chain of infection

  1. Reservoir host – an organism – usually animal or human – that harbors and nourishes a pathogen.
    1. Often a reservoir host give a pathogen a home for a long time without suffering any ill effects from it.
  2. Portal of exit – the exit includes respiratory, gastrointestinal, urinary, and reproductive tracts of the body.
  3. Means of transmission – direct contact with infected person, discharge or excreta (waste products)
    1. Indirect contact – inhaling infected air droplets from a cough or sneeze, contaminated food.
  4. Portal of Entry (new host) – pathogens enters the body of a new host. Either through respiratory, urinary, and reproductive tracts, skin and mucous membranes, or blood.
  5. Susceptible host – Someone who is available and capable of being infected by a pathogen.
    1. Someone who is unable to fight off infection

Stages of infection

Invasion – Pathogen enters the body through the portal of entry: respiratory, digestive, urinary tracts and skin

Multiplication – reproduction of pathogens

Incubation period – May vary from several days to months or years during which time the disease is developing but no symptoms appear

Prodromal Period – First, mild signs and symptoms appear; highly contagious period

Recovery period – Signs and symptoms begin to subside.

Acute infection – Common illnesses that afflict the human body are considered acute infections. These may include the common cold and influenza.

  • Acute infections have rapid transition from invasion of the pathogen to the prodromal period.

Chronic Infections – More serious than acute infections – effects of the disease causing pathogen can last a very long time.

  • Transition stages from invasion to the prodromal period will vary based on the type of infection.

Latent Infections – characterized by periods or remission and relapse

  • Remission – when the disease has been treated and there are no longer any signs or symptoms present.
  • Relapse – when the same infection reoccurs.

This is common in infections such as cold sores (herpes simplex virus types I & II)

Opportunistic Infections – occurs when host’s immune system has already been imparied by another disease-causing pathogen.

  • For instance those who have HIV, Cancer, and Lupus have compromised immune systems and suffer infections (such as pneumonia, oral thrush)

Nosocomial infections – acquired in medical facility-generally the hospital setting. The pathogens were not in the patient’s body when he or she came into the facility but rather were introduced into the body because of poor aseptic technique in the facility.

  • Bloodstream infections – improper venipuncture or IV lines procedures
  • Urinary tract infections – improper catheter procedures
  • Surgical site infections – improper wound care

Inflammatory response to infection

The body may react to the presence of pathogen. This process results in the dilation of blood vessels to allow increase blood flow, production of watery fluids and materials (exudates such as pus), and invasion of neutrophils and monocytes into injured tissues.

  • Neutrophils and monocytes are type of leukocytes (white blood cells) that perform phagocytosis, which means that they engulf (eat) and destroy disease-causing pathogens.
    • Cardinal Signs of Inflammation
      • Redness
      • Heat
      • Swelling (edema)
      • Pain

Some other signs are

  • Abnormal white blood cell count
  • Fever
  • Increased pulse rate
  • Increased respiration rate

Prevention and Protection

Human body has several natural barriers to infection, Skin being the largest natural barrier to infection.

The gastrointestinal tract contains hydrochloric acid (HCI) which has bactericidal (bacteria-destroying) action.

Lymphatic system and blood – produce antibodies to identify and neutralize or destroy disease-causing pathogens that enter the body. Leukocytes actively fight pathogenic microorganisms through phagocytosis – the process of engulfing, digesting, and destroying pathogen.

Antibodies – protein substances produced by lymphocytes in the spleen, lymph nodes, and tissue, and the bone marrow – react in response to antigens

  • Antibodies have the ability to neutralize antigens or make them more susceptible to phagocytosis

Immunity a resistance to disease, is said to have occurred when enough antibodies have been produced to provide protection for weeks, months, or years. Immunity is either innate, active, or passive

Innate – natural immunity. It is the body’s first line of defense against pathogens including skin, mucous membrane and tears.

Active – Acquired active – a person is immune to a disease because he or she has been previously exposed and has developed appropriate antibodies.

  • Artificially acquired active – Immunity induced through vaccine

Chapter 4 – Assist in Minor Surgery

Before surgery

  • Complete insurance forms
  • Obtain consent forms
  • Meet with patient. Assignment: Health Records Management Paper
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