Health Records: Documentation and Protection

Current standards associated with health record content and documentation include methods, terminologies, and protocols that allow for collecting, exchanging, storing, and retrieving valuable health-related information. The standardization of such data includes data element definition, data interchange formats, terminologies, and knowledge representation (Aspden et al., 2004). Therefore, when dealing with health data, the process of standardization can be implemented through three key recommendations. First, it is necessary to define what should be collected; second, decide how what is collected should be represented; and third, determine how the data should be encoded. The first two recommendations apply to both computer-based and paper-based systems. For instance, lab test results will include the same data regardless of their format. Data elements of specific information can be separated together on the basis of datasets used for measuring outcomes, processes for evaluating the quality of care, and making conclusions on patient safety. The rationale for the third recommendation is that terminologies alone cannot provide the desired levels of specificity. To establish the comparability of data, it is necessary to establish specific codes for each set of terms for representing data elements.

Privacy, security, and confidentiality standards, which fall under the Health Insurance Portability and Accountability Act, encompassing regulations safeguarding some health information’s security and privacy. Health data recovery is a significant problem at the present time because the existing regulations cannot ensure safe and quick methods within the IT infrastructure. This is because most organizations have data backup solutions that have not been effective for recovering data in emergencies. The critical recommendations for establishing the privacy, security, and confidentiality of health data include the implementation of solid controls for data access, integrating encryption methods, and performing regular data backups. However, accomplishing these tasks will become possible with the consistent training of healthcare employees, especially in areas such as data breach identification, handling sensitive health information, and implications of privacy policy violations.

Within the Data Protection Act of 2018, individuals are given distinct rights for accessing, correcting, and deleting their personal data that institutions may hold, thus representing a step in the direction of strengthening personal data privacy efforts (“Data Protection Act 2018,” 2018). Within the limits of the act, it is essential to pay attention to restoration methods as crucial components of data management, which may help ensure that access is provided only to authorized entities. Using such methods as encryption, authentication, and decryption can help guarantee the protection of sensitive data. Through installing firewalls, healthcare facilities can improve their efforts of monitoring and controlling both outgoing and incoming traffic within their networks. Overall, all measures aimed at securing data should be focused on combining convenience and ongoing monitoring of health information handling.

The expanding use of mobile health technologies represents a unique opportunity for accessing health data and services from multiple locations. Despite the benefits, such issues as data breaches, malware, and unauthorized access persist (Aljedaani & Babar, 2021). To address these challenges, it is recommended to implement such measures as multifactor authentication, encryption of all relevant data, and education of users on the risks linked to mobile health technologies. The following of recommendations mentioned above can help reduce the risks of unauthorized data use while also offering more effective measures for managing health data in the context of modern challenges and technological updates.

References

Aljedaani, B., & Babar, M. A. (2021). Challenges with developing secure mobile health applications: Systematic review. JMIR mHealth and uHealth, 9(6), e15654. Web.

Aspeden, P., Corrigan, J. M., Wolcott, J., & Erickson, S. M. (2004). Patient safety: Achieving a new standard for care. National Academies Press.

Data Protection Act 2018. (2018). Web.

Cite this paper

Select style

Reference

NursingBird. (2024, November 26). Health Records: Documentation and Protection. https://nursingbird.com/health-records-documentation-and-protection/

Work Cited

"Health Records: Documentation and Protection." NursingBird, 26 Nov. 2024, nursingbird.com/health-records-documentation-and-protection/.

References

NursingBird. (2024) 'Health Records: Documentation and Protection'. 26 November.

References

NursingBird. 2024. "Health Records: Documentation and Protection." November 26, 2024. https://nursingbird.com/health-records-documentation-and-protection/.

1. NursingBird. "Health Records: Documentation and Protection." November 26, 2024. https://nursingbird.com/health-records-documentation-and-protection/.


Bibliography


NursingBird. "Health Records: Documentation and Protection." November 26, 2024. https://nursingbird.com/health-records-documentation-and-protection/.