HIS MT 102 LAB - File Management and Healthcare Documentation

File Management and Healthcare Documentation

are essential components of digital healthcare systems because they ensure that patient data is accessible, accurate, secure, and well-organized

File Management

refers to the systematic process of creating, naming, organizing, storing, securing, and retrieving digital files within a computer.

File Management

ensures that patient record and laboratory data are properly structured and can be retrieved quickly when needed.

Loss of Patient Records;

Duplicate Files;

Delayed Diagnosis;

Medical Errors;

Data Privacy Breaches

Enumerate 5 outcomes that result from Poor File management:

Healthcare Documentation

the accurate and systematic recording of patient and clinical information in electronic or manual formats

Patient demographic records;

Laboratory test results;

Physician Notes;

Nursing Notes;

Prescription Notes

Enumerate 5 records in Healthcare Documentation:

Improve patient safety;

Enhance communication among Healthcare Professionals;

Support clinical decision-making;

Reduce medical errors;

Improve workflow efficiency;

Ensure Legal Compliance;

Protect patient confidentiality

Enumerate 7 results when following proper file management and documentation:

Accuracy;

Completeness;

Timelessness;

Clarity;

Confidentiality;

Standardization

Enumerate 6 principals of good healthcare documentation:

Accuracy

Information must be correct

Completeness

No missing data

Timelessness

Recorded immediately

Clarity

Easy to understand

Confidentiality

Protect patient information

Standardization

Consistent format

Role in Health Information Systems

File management and documentation are essential in:

Electronic Health Records (EHR)

Hospital Information System (HIS)

Laboratory Information System (LIS)

Pharmacy Information System

Electronic Health Records (EHR)

Hospital Information System (HIS)

Laboratory Information System (LIS)

Pharmacy Information System

enumerate the 4 areasthat File management and documentation are essential in:

Role in Health Information Systems

They ensure smooth digital healthcare operations