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Sample Courseworks on Electronic Health Record

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Sample Courseworks on Electronic Health Record

 

Data type

Data collection

Type of data to be collected

Explanation

Registration and scheduling

This data would be collected at the hospital’s reception and it would be collected by receptionists. Interviews would be conducted to collect registration data.

 

For registration, patients’ information such as name; age; gender; race/ethnicity; insurance status; place of residence; and telephone number would be collected for identification purposes as well as billing purposes.

With regard to scheduling, details to do with appointments, duration of visits, start and stop time, and follow-ups would be provided (Carter, 2008). 

Registration data falls under structured data because it consists of standardized information such as dates, identification numbers, patients’ names and diagnosis codes. The same case applies to scheduling data because it consists of standardized data as well.  

Laboratory

This type of data would be collected in medical laboratories.

The doctors or other physicians would order for laboratory tests whereas laboratory technicians would conduct those tests and collect data from patients.

Once laboratory technicians collect data from patients, they would send it to doctors and other physicians for analysis.

The type of data that would be collected include patient’s weight and height, respiratory rate; body temperature; pulse; blood pressure; and body mass index among other types of data.

This type of data would be structured in the sense that it appears in a standardized manner that is easy to read and in most cases easy to retrieve from a database.

Ambulatory

This data would be collected by the clinical officers in charge of ambulance services. The data would be collected during emergency services. As a result, the data may appear in an unstructured manner. The ambulatory data that would be collected would not be sent to anybody, but it would be kept for future reference.

The type of the data that would be collected during ambulance services would include patient’s body temperature and the treatment given to the patient among other patient’s details. In most cases, the process of collecting data would be done on paper work and to a great extent it would be unstructured because the patient may not be able to communicate effectively with the clinical officers.  

Given that it may not be possible to collect structured data from a patient attended in an ambulance, the ambulatory data would to a great extent fall under the unstructured data. Although effort has been made to computerize ambulatory data, the fact remains that ambulatory data is collected in an unstructured manner (Carter, 2008). Consequently, ambulatory data would fall under the unstructured type of data.

 

Dictation and transcription

For transcription, physicians would interview patients and as they do this, they would type the information they obtain directly from patients into the note sections of the medical records. At other times, physicians may simply use speech recognition methods to create narratives (Carter, 2008).

For dictation, physicians would provide information to other physicians or their assistants and have those people type information into the note section of the medical records.    

The type of data that would be collected through transcription would include the way a patient feels whereas the type of data that would be collected through dictations may relate to surgical operations and other operations.     

The type of data that would be collected through dictations and transcriptions would appear in an unstructured manner. Consequently, this type of data would fall under the unstructured data and it would broadly be a reflection of the original data.

 

 

Reference

Carter, J. (2008). Electronic health records: A guide for clinicians and administrators. Philadelphia: ACP Press.

 

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