As an HIM chart analyst, you are reviewing the hospital’s electronic health records of discharged patients. At one point, you notice some discrepancies in a patient’s EHR. In one area, the record states that the patient has “no known allergies.” Another area of documentation indicates that the patient is “allergic to penicillin.”
You check recorded names, dates of birth, and reasons for hospitalizations in all of the documentation, and all of the information seems to refer to the same patient. However, a few other areas show inconsistency or poor documentation, such as the difference in the patient’s height during different hospitalizations, no mention of a preexisting chronic illness in the latest history report, and the conflicting documentation on the penicillin allergy— information that could be critical to future care.
Write a 1- to 2- page essay describing the steps you would take to follow up on these discrepancies. Explain how you would determine if all of the information in the record is from the same patient, and whether the discrepancies are the result of identity theft or improper documentation or if records for another patient have been comingled with the original patient. Upload your submission and save your changes.