Question

Record of Care, Treatment, and Services (RC):

Describe how this standard or process relates to health information management or health informatics in the hospital setting.

Answer 1

Record of Care, Treatment, and Services” (RC):

Background-

United States spends a huge proportion of total GDP on health care services and health insurance of people in the US. In recent years cost towards this healthcare scheme was tremendously increased and hence to address the rising costs in health care, governing bodies required to adopt a series of programs and recommended for transforming the health care system through the use of health information technologies (HIT) a key component of the Health Care Reform Act.

As one key component of this technology, a documentation of patient was maintained. It was later termed as “Record of Care, treatment, and services” which contains detailed information about the patient clinical history starting from the time of admission till discharge of the patient from the hospital or healthcare organization.

Record of Care, Treatment, and Services” (RC) an important tool of health information management or health informatics in the hospital setting:

1. Components of a complete clinical record can be preserved in form of an electronic record or physical records in medical files.
2. This could be used later for detailed study by the healthcare practitioners or the medical students as the case study for future treatments and complications in similar kind of treatments.
3. These documents contain highly detailed data collected about a patient from the moment he or she enters the organization to the moment of discharge or transfer.
4. It does not only functions as a record of patient history or episodes of care but also acts as a method of communication between practitioners and healthcare staff involved in patient treatment.
5. It acts as a clinical aid for continuity of treatment and decision-making tool for doctors due to a detailed summary provided through this record.
6. It acts as an important way of information transfer in the case for transfer of a patient from one organization to another so as to understand the treatment followed to the patient till date and give a rough idea to the new caretaker about the patient's state of disease and treatment.
7. In bigger organizations where patient care is episode oriented and practitioners hardly visit the each patient twice or thrice depending on the patient’s need and the organization’s scope of services; in such cases, patient’s episodes must be carefully documented to manage the patient treatment as proper function. Here these records play an important role as a data bank for the health center.
8. Information transcribed in these records are authenticated and can be used for case study and surveys for future health services.
9. Authenticated information can be preserved for insurance and medical track records of individuals.
10. RC aids in recording the health information of united states people starting from birth till the death which can be analyzed by various ways such as how much average lifespan a person lives, his healthy lifestyle, allergic symptoms.
11. RC also manage to preserve the track record of pharmacovigilance data of medicinal drugs used during treatment which helps to understand the pharmaceutical market the adverse impact of medicines if any.
12. Patient health record also aids to monitor the dosing schedule as medicinal charts involved along with dosing time can be utilized to manage the dosing to the patient by nursing staff.
13. The record contains all the historical background of a patient along with the previous history of illness and treatments which can be understood and studied thoroughly by medicinal practitioners of a hospital to identify complications during surgeries and operations.