...more facilities switching over to electronic medical records. The few who are hesitant to take the plunge and convert over to electronic medical records may be thinking about the cost of the software. Also, the time it takes to train all their employees and what that could cost the facility. Many think about what happens if the system goes down and all the problems that could occur from that. Even though there can be problems that occur with the EMR there are pitfalls to keeping the manual records as well. When it comes to manual records only one person at a time can view it; making other staff members who need to access it wait until it is available. Also, different healthcare providers may have different documenting styles, making charts inaccurate or not legible. Finally, manual record could easily become misplaced or lost when getting filed away making many workers waste time trying to locate it. Both forms of medical records are a legal document that holds personal information that is not to be seen just by anyone. They also contain most of the same kind of information from lab reports to progress notes all the way to patient history. Also, both kinds of records need to be created and maintained by administrative and clinical staff members. Many people may get confused when they see electronic medical records and electronic health records and think they mean the same thing. They are in fact different; EMR’s have standard medical and clinical data that was gathered by ones...
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...patient’s information is not documented in their medical record we cannot receive reimbursement for those services. We cannot bill for services that has not been documented, this is unethical and considered fraud. In order to avoid these issues we as staff must provide these minimum documentation in a patient’s chart. These documents are as follows: Chief Complaint of the patient for the date of service; the patient’s medical history; any physical exams performed on the patient at the time of service; new discoveries or findings will need to be documented; additional diagnostic testing ordered by the physician to include medical necessity of such testing; an assessment of the patient needs to be documented as well; a conclusion or doctor diagnosis must be documented if one is present at the time of visit; a treatment plan must be documented along with any doctor recommendation s for a follow-up visit. In addition to minimum documentation requirements, there are some electronic solutions to help the staff ensure accurate evaluation and management coding. Those electronic solutions are included in our database, EZ Claims, as a claim scrubber. This claim scrubber will notify staff if we are billing inaccurate E&M codes based off documentation requirements in our EHR system. For example, if an established patient who is 18 years of age being seen on July 15, 2016 as one involving a detailed history, detailed examination and medical decision making of moderate complexity we know...
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...Journal Article Review Introduction “A Guide to Taking a Patient's History,” an article written by Hillary Lloyd and Stephen Craig, which was published in volume 22, issue 13 of the Nursing Standard journal in December 2007 issue. The article provides an overview of professional processes involved in attaining patient’s history, emphasizes preparation of a comfortable environment, and exemplifies the significance of using effective communication skills to assist practitioners with obtaining a comprehensive and an accurate patient history while using a structured systemic approach in a variety of settings. Summary of the Article “Taking a patients history is arguably the most important aspect of a patients assessments, and is being undertaken by nurses” (Crumbie, 2006, as cited in Lloyd & Craig, 2007, p. 42). An accurate and comprehensive patient history is imperative and “cannot be overstated” (Crumbie, 2006, as cited in Lloyd & Craig, 2007, p. 42) since it provides clinicians with the most essential information needed to establish an effective and a patient focused plan of care. Lloyd and Craig recommends preparing a comfortable environment and using effective communication skills in a logical and systematic approach to begin this process to achieve the best patient outcomes. First, the nurse should begin with preparing the environment by ensuring it is easily accessible, well prepared, safe for patients and or/and their family member(s), and preferably in a location where...
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...promote new products and new services the ways that this can be done would be through electronic medical records, or any form of a web-based communique. Some types of communications can also make the patient feel safer and also help the organization save time and money. Electronic medical records give the patient some benefits that are to the advantage of them as well as the provider. It allows the patient to keep their medical records up to date and accurate so that way there are no problems with such things as allergies, surgeries, or medications that are being taken. This is a way for the patient to keep accurate records of their medical history as well as keeping the provider updated at all times (Brooks, R., Grotz, C.). This an effective means of communication between the patient and provider by allowing the provider to give access to some of their records that will allow the patient to adjust certain things in their lifestyle or medications without going in to see the provider for something that would not require an office visit. This type of communication can allow the provider to keep a better watch on the consumer’s progress that will allow the provider to release some test and results to the consumer and the provider can also let the consumer know exactly what the their instructions are without being misinterpreted (Brooks, R., Grotz, C.). Electronic Medical Records is a form of communication that is developed to make health care records easier to update...
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...1. What cardiopulmonary physical assessment findings might be present in a patient who smokes? How would you approach this patient for history taking and assessment? There are several physical assessment findings in patients that smoke and a through respiratory and cardiovascular physical exam should be conducted. Dyspnea, coughing with our without sputum, and wheezing may be indicative of a respiratory disease related to smoking. Also, smokers may have a barrel chest, hypoxia, and take much longer to exhale a full breath. More severe assessment findings would include accessory muscle use, pursed lip breathing, tri-poding, and nail bed cyanosis. A complete family history, patient medical history and history of present illness should be obtained followed by a complete set of vital signs. Observe the rate, depth and rhythm of respirations. Note the shape and configuration of the chest wall. Severe thoracic deformities, such as scoliosis and kyphosis may reduce the lung volume. Observe the position your patient is in while at rest to take a breath. A relaxed position and the ability to support ones own weight with arms comfortably at the sides. Patients with respiratory diagnoses may sit in a tripod position (leaning forward with arms braced against knees, chair or bed). (Jarvis, 2012 p422.) Assess skin color; a bluish discoloration (cyanosis) can indicate hypoxia. Assess chest expansion by placing your hands on a patient’s posterolateral chest. Gently bring your thumbs to...
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...primary care physicians, based on the amount of doctors graduating and an increase demand of healthcare. Having said this, the atmospheric state in the healthcare environment can be described as barred linear unit in which everything within is in an incessant movement, whether it’s the personal, semantic role, and/or the application. In this crucial environment, access to patients’ medical record in a timely manner is essential in providing efficient and quality patient care. In a town meeting held in Northern Virginia Community College in Annandale, Va., President Obama called for fixing the inoperative healthcare system by investing in electronic medical records. President stated, “ I know that people say the costs of fixing our problems are great – and in some cases, they are”. He also stated that, “The costs of inaction, of not doing anything, are even greater. They’re unacceptable.” In an effort to minimize the cost of our healthcare system, he emphasized that: "When everything is digitalized, all your records - your privacy is protected, but all your records on a digital form - that reduces medical errors. It means that nurses don't have to read the scrawl of doctors when they are trying to figure out what treatments to apply. That saves lives; that saves money; and it will...
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...correct information in the patient medical record. When a person comes to a health care facility or Doctor Office for any type of medical care a patient record is generated and updated on each visit. Any Information concerning the patient’s medical history and symptoms of the complaint are listed in the medical record by the administrator. The Records Administrator makes certain that the patient’s medical chart is completed with all forms being completed correctly. Records Administrators really don’t have contact with patients. Because the administrator does converse daily with insurance companies, and the medical staff it is crucial to ensure they have good communication skills. Records Administrators do prepare medical reports that consist of payments, disease evaluations and comprehensive care studies. The Records Technicians (RHIT) are to keep up-to-date reports on the treatments that the patients receive and while also maintaining a thorough and detailed patient medical history information, and they make sure that the information is accessible to any of the medical staff. The record technician need to make sure that a patient's illness and any treatments are completed in the records for the insurance companies, also the patient may come back to the healthcare facility for any treatment. The record technicians need to make sure to code all of the information from the patient’s medical records before it’s entered into the medical records system. One of the other duties...
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...THE FEDERAL POLYTECHNIC NASARAWA,NASARAWA, NIGERIA MEDICAL EXAMINATION FORM ADMISSION DATE: 2013-01-14 MEDICAL EXAMINATION FORM (THIS MEDICAL REPORT FORM MUST BE COMPLETED BY NEWLY ADMITTED STUDENTS) SECTION A: (TO BE COMPLETED BY THE STUDENT) NAME (in full) : DATE OF BIRTH : SEX: UKPO YUSUF OKAH TELEPHONE MARITAL STATUS LAST OCCUPATION NAME AND ADDRESS OF PARENT/GUARDIAN PHONE PREVIOUS MEDICAL HISTORY Previous Illness: Date of Illness: 1. Childhood 2. Adult Previous Operation: Date of Operation: Previous Injuries Date of Injuries: VACCINATION WITH DATES Smallpox Triple Vaccine (DDT) Polio Miletus Typhoid Yellow Fever Meningococcus Meningitis *Do you suffer from any other personal health defect e.g Sight, Hearing impairment and whether or not adequately? ________________________________________ *Was it corrected? ___________________________________________________ *Have you been treated for Nerve or Mental Illness__________________________ *How would you rate your own health status? (poor, fair, good, excellent) HAVE YOU SUFFERED FROM OR DO YOU SUFFER FROM ANY OF THE FOLLOWING Tuberculosis Yes No Heat in the Head or Body Yes No Sickle Cell Anemia Yes No Hypertension Yes No Diabetes Yes No Hard Disease Yes No Epilepsy Yes No Peptic Ulcer Yes No Gonorrhea or Syphilis Yes No Mental Illness Yes No Pile(Heamorrhoid) Yes No Asthma Yes No ...
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...Health History D.S is a 50 years old male, born and raised in Rochester, NY. Widower with 8 children. Work as security guard at Monroe Community College (MCC). SOURCE OF HISTORY Patient- very reliable historian Medical record CHIEF COMPLAINT Sudden onset of chest pressure. Describe pain as “aching, heavy feeling in the chest” PRESENT ILLNESS Chest pain/pressure that is located primarily in the substernal area not radiating to arms that began acutely about an hour ago and lasted for 45 minutes. Started at work, pain was at it’s worst that made patient to seek help. Describes pain as aching, heavy feeling. Positive for diaphoresis, dizziness, malaise, palpitation but no nausea/vomiting, shortness of breath and symptoms are aggravated by nothing. PAST HISTORY General Health: Obese but generally healthy Childhood Illness: Had chicken pox in childhood, no measles/mumps/rubella/whooping cough/rheumatic fever/polio Hospitalizations/surgeries/Injuries: Excision of forearm lipomas in 1998, tonsillectomy in 1981, denies motor vehicle injury or any major injuries. Previous Medical History: Obesity, umbilical hernia, COPD, Bronchitis, CAD, Hyperlipidemia, chronic back pain, denies any mental illness CURRENT HALTH STATUS Immunization History: Tetanus shot in 2000; not sure about other immunization Allergies: Bactrim-rash Screening test: No PPD, Guiac, uninalysis Environmental hazards: works as security guard-some physical threats Use of safety measures:...
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...Week 2 Checkpoint Different standards of medical records documentation have different compliance plans that correspond to them. Staff members must follow all billing rules and medical facilities have to be certain that this is taking place. When filing medical records they have to be accurate: they have to contain the patient’s conditions and diagnoses, and they must trace the patient’s course of care, also they have to have the patient medical history, including family history. Medical records of patients are legal documents; physicians may use them in their defense if they are accused of improperly treating patients. Doctors have to provide documentation for the reasoning behind treatment decisions as a means of protection from lawsuits. This has to be done because it helps prevents lawsuits for malpractice. When the medical facility has rules and compliance plan in place, they have showed that they are committed to finding and preparing any types of weak spots in their management. Some of the areas that are helped when compliance plans are place are: making sure your employees are educated and trained for their position, by doing this is helps prevent future problems in the work place and avoid any type of legal action that can be taking against them. Not just the coding and billing are covered in the compliance plans; every area of government regulation of medical practices is coved as well. The medical billing process has ten different steps that re connected to...
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...and can be implanted into your body. Your identity, personal medical records, and other important information can go with you where ever you go and save you the hassle of looking for your wallet and remembering pertinent personal information. That chip can also monitor your vital signs and be used by others to locate you, using global positioning satellite technology, no matter where you might be. These in other words, mean that you will be a cyborg, which is part human and part machine. This leads to the discussion of ethical stand point and the broad uses of it. One must also ask themselves that will this lead to a helpful outcome in its future uses, or would you see it as a serious threat to your privacy and a potential tool for the government to gain power on individuals and for businesses to make a living out of personal life. This technology is not just in movies such as Jonny Neumonic, Cyborg, Gattica and Matrix, but is here now and nearly ready to be used. It is the new product by Applied Digital Solutions of Florida named the VeriChip. On October 12, 2004, the Food and Drug Administration approved VeriChip for medical applications in the United States. This approval allows VeriChip for use of strict identity purposes, and uses in blood type checks, allergy identification and medical history of unconscious patients. This is meant as a basica a substitute for the previously used Medical tags that was worn as a bracelet and or necklace. However, the...
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...Introduction “A guide to taking a patient’s history” is an article which was written by Hiliary Lloyd and Stephen Craig, published in volume 22, issue 13, of Nursing Standard in December 2007. Lloyd and Craig describe the process of taking a health history and explain how environment and other factors affect the accuracy of the health history obtained. This article provides different methods to taking a comprehensive history and the order in which to do so. Summary of the Article Taking a patient’s health history is an integral of patient assessment and it is important that nurses hone their assessment skills while expanding their role as a nurse. Before a health assessment is taking the nurse must first have informed consent from the patient. While taking a health history it is important to choose the right environment, free from distractions if possible and safe for the patient and nurse. The nurse should convey respect for the patient as a person and maintain a level of privacy and dignity. Good communication skills are essential; the nurse must introduce herself to the patient, develop a rapport with the client by being professional, friendly and show interest by actively listening to the patient, the patient should not feel rushed or hurried. Nurses should refrain from using medical jargon when possible and utilize verbal and non-verbal communication skills. It is important to consider culture when taking a patient’s health history. Perform a cultural assessment of the patient...
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...exposing their clients and their business to great danger (Mead & Wicks, 2004) The text identifies a couple of issues. First, Reiger was not informed of the genetic tests he underwent, given that he submitted to a routine annual drug and alcohol examination. Second, the release of Reiger’s genetic results (not related to the examination reasons) obtained during routine medical screening to his employer without prior notification and consent was unethical. Equally, the possibility of discrimination against Reiger based upon health reasons/medical history is high. Also, clients/public could be exposed to risks, which could occur if results of Reiger’s medical screenings are not holistically considered. Consequentialism, universalism, rights, justice and fairness are relevant ethical models that apply to the case in hand (Mead & Wicks, 2004 Overall, the key fact in the text, according to Mead & Wicks, 2004, is the discovery of a potential genetic disorder (Huntington’s disease) in David Reiger, a seasoned pilot with Danville Airlines in Milwaukee ensuing from a routine blood test for alcohol and drug use. Also, medical science cannot determine when the disease will begin to manifest in Reiger-like many other carriers of the infected genes (Mead & Wicks, 2004) A key factor also is that HD disease results into major physical and mental deterioration in victims, which presents a big risk in having Rriger fly as a pilot. Testing Reiger without his consent was a violation of his right...
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...Health Services Office MEDICAL EXAMINATION FORM DATE: _________________ SCHOOL YEAR: __________ ID NUMBER: _____________________ COLLEGE: _____________ LAST NAME: _____________________ FIRST NAME: ______________________ M.I._______ CONTACT#: ________________ CONTACT PERSON IN CASE OF EMERGENCY: ________________________ RELATIONSHIP: ______________ CONTACT#: _________________ AUTHORITY TO CONDUCT MEDICAL EXAMINATION I, __________________________, ____years old accept and understand that I am required to undergo a physical examination and chest x-ray to determine my fitness and well-being as a student. I fully understand that the results will be held as confidential medical records and will be used by the University for my care and treatment. My health information cannot be released to third persons except with my consent or unless the disclosure of the information is required by law. I also accept and understand that the procedures are requirements for the next academic year enrolment. I acknowledge that my medical records will be retained by the University for a period of 5 years from examination or health visit. ________________ Signature of Student PHEX Consultation Details Physical Exam (to be filled-out by a nurse/doctor) Medical History (updated) Blood Type_______________ 1.__________________ _ Blood Pressure____________ 2._______________________ Resp. Rate_______________ 3._______________________ Temperature______________ 4._______________________ Pulse Rate________________...
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...correct medical term for each of the definitions below. Definition Medical Term 1. rectal hernia Rectocele 2. excision of the stomach Gastrectomy 3. inflammation of the kidney Nephritis 4. enlargement of the liver Hepatomegaly 5. incision to remove a stone Lithotomy 6. fixation of the intestine Enteropexy 7. artificial opening in the colon Colostomy 8. incision into the abdomen Laparotomy 9. absence of one or both testes Anarchism 10. rupture of the uterus Hysterorrhexis 11. excision of the prostate gland Prostatectomy 12. visual examination of the vagina Colposcopy 13. surgical repair of a testicle Orchiopexy 14. discharge of milk Galactorrhea 15. difficult labour or delivery Dystocia 16. suture of the tongue Glossorrhaphy 17. surgical puncture of the abdomen Abdominocentesis 18. pus in the urine Pyuria 19. pertaining to above the kidney Suprarenal 20. narrowing of the urethra Urethral Stricture Question 2 Give the meaning of each of the abbreviations below. Abbreviation Medical Meaning 1. LUQ Left upper quadrant 2. GI Gastrointestinal 3. OGD Oesophago-gastro duedenoscopy 4. CVS Chorionic villus sampling 5. STD Sexually transmitted disease 6. IUD Intrauterine device 7. TURP Transurethral resection of the prostate 8. DRE Digital rectal exam 9. UTI Urinary Tract Infection 10. C&S Culture and sensitivity Question 3 Using your learning resources, give a brief definition of each of the following medical terms...
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