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Protection of Health Record Documentation

Standardizing medical documentation

Standardizing medical documentation has sufficient benefits for the communication between doctors and the patient, improving its quality and making cooperation more productive. The healthcare system, in general, may undergo positive changes due to the innovations in the work with the problem-oriented record. The physician is fully responsible for the clear and structured notes they make in the record about the patient, and the medical coders help to systematize it. Eventually, it helps to improve the quality of the service and prevent the physicians from burnout caused by the great amount of unsorted information.

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Thus, for the physician, it may be obvious what is in the notes, but it also should be understandable for the coder, so there would be no mistake in the patient’s diagnosis or treatment. In addition, it is critical to differentiate the subjective and objective information in the record. Subjective data includes the doctor’s observation of the patient’s condition, suggestions, notes from the conversation, and personal assumptions (What are SOAP notes? How standardized notes improve healthcare, 2022). However, all impressions have to be supported by facts, and some of the subjective observations include medical and family history, current symptoms, and diseases. Objective data only aims to support what was mentioned in the subjective section. Mainly it consists of numbers and measurable facts such as body temperature or pulse (What are SOAP notes? How standardized notes improve healthcare, 2022). Therefore, subjective information is the physician’s observations supported by evidence, and objective data supplements those suggestions with numeric measures.

In order to find the current diagnosis, the coder should pay attention to the assessment category. This section concludes all the outcomes and notes made before in order to identify the illness or diseases considering the gained knowledge about the patient’s condition (What are SOAP notes? How standardized notes improve healthcare, 2022). It also includes the current progress and changes in treatment if needed, although more details about the medication can be found in the plan section.

Protection of health information

Protected health information is a patient’s data that consists of some aspects that may expose their identity. For example, some PHI pieces include the phone number, address, information about the insurance, photograph, or dates related to the particular individual, such as date of birth (Alder, 2021). Although some of the pieces may seem insignificant, they still can lead to the leak of the PHI. Some data may not include the patient’s name, but they still can be found easily on the internet through a web search and special programs.

Thus, doctors may accidentally reveal the PHI of a person by asking the employees not involved in the treatment to send the results of the analysis or send a letter regarding some issue by email. Mentioning the name of the patient and the state where they live is also considered the accidental disclosure of the PHI information. It can unintentionally happen when the physician mentions the data in front of other patients or individuals unrelated to the specific person and their medical history. Another way of revealing the PHI is by leaving the sources with information, such as computers or safes with the records without the guard. Eventually, some other people and personnel can get access to this.

In order to avoid the leak of PHI, physicians should perform their responsibilities themselves and not pass them on to other healthcare employees. They should also be trained to refer to the patient in the presence of others in a neutral way or in third person pronouns. Moreover, all the technologies in medical institutions have to be provided with innovative technologies to protect the electronic system on the devices (Alder, 2021). In addition, physical ways of keeping should always be locked when the responsible employee is absent, and the keys or codes to the safes should not be left unattended.


Alder, S. (2021). What is considered protected health information under HIPPA?. HIPPA Journal. Web.

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What is SOAP notes? How standardized notes improve healthcare. Cybernet. Web.

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