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Step 1: In preparation for the electronic health record (EHR) implementation, you are assisting the information technology (IT) and admissions departments in creating a data dictionary for the master patient index (MPI). Discuss the following:

  • Describe 3 data elements that are contained in the MPI.
  • State what is acceptable data for each element.
    • For example, the element of marital status must allow the terms single, married, widowed, and so forth.
  • Do the elements that you have selected meet the Health Information Technology for Economic and Clinical Health (HITECH) Act’s 3 stages of meaningful use?
  • Discuss how this relates to the patient access and billing functions within a health care organization.

Step 2: While working with the IT and clinical departments, you are assisting them in creating a drop-down menu for the histories that are recorded in the patient record. You will be responsible for making sure that 2 types of histories include all of the elements required. Choose 2 of the following histories, and list the elements that must be included as part of that history:

  • Past medical history
  • Chief complaint
  • Past surgical history
  • Past family history
  • Social history

Be sure to support your information by citing at least 2 references using APA format.

 

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