... Health Record Worksheet In 150 to 350 words, explain the importance of a health record. Support your explanation using your assigned readings. Personal health records can help a provider's patient better manage their care. Having important health information, for example, immunization records, lab results, and screening due dates in electronic form makes it simple for patients to update and share their records. Patients can be more engaged with their wellbeing and health care. PHRs can advance better health care by offering patients some assistance with managing information from different providers and enhance care coordination. Having an online PHR can be useful if there should be an occurrence of crises particularly if a patient is traveling. Administrative expenses can be reduced utilizing a PHR to give patients simple access to electronic prescription refill and appointment scheduling applications. With PHRs, health care staff can invest less time searching for patient-requested information and respond to patient inquiries. Use the following table to identify and list at least five key components of a health record. Additionally, include a 50- to 100-word description of each component. Support your descriptions using your assigned readings. |Component of the health record |Description | |Patient Management |Required for patient registration...
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...The role of the Medical Office Manager in risk management is to identify and evaluate risks as a means to reduce injury to patients, staff members, and visitors within an organization. They need to make sure office polices are being followed, they need to maintain accurate records, and maintain a good rapport with patients their families. Medical office managers have to make sure that the staff follows policies to ensure that negligence and malpractice does not occur. There are federal laws that the Medical Office Manager should be an expert in knowing and able to educate their staff, and make sure the laws are being followed (Andress, A, 2009). It is important that the office manager understands all the laws and make sure that all the staff...
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...purpose of reimbursement to providers for patient encounters within the United States. E/M is used in determining the type and extent of the condition of a patient. Current Procedural Terminology (CPT) Codes are used in conjunction with E/M codes to document and bill for reimbursement of specific services. Evaluation and Management Services To determine the level of evaluation and management services that are provided to a patient, the key components and contributing factors need to be assessed. The procedure would be to identify if the patient is a new or established patient, where the patient is being seen, is this a consultation, is the patient being seen for an illness or preventive care, determine the level of history, the level of examination, the level of medical decision making (MDM), then assign the proper code (Abraham, 2011). Evaluation and management service levels are based on any and all documentation found in a patient’s medical record. There are different levels of service for which key components are based on; history, examination and medical decision making. These three components are a reflection of what occurred and is recorded by the doctor in the patient’s medical record. You will find these key components in every patients case with the exception of counseling encounters. By using these key components, you are able to decide what level of service to use (Abraham, 2011). History is what the patient tells the doctor, There are four elements...
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...Database Records and Relational Data Worksheet Complete Parts A and B of this worksheet. Cite any outside sources consistent with APA guidelines. Part A: Database Records l Answer the following patient information questions using the table provided. Refer to figure 4-10 on p. 83 of Health Information Technology and Management for assistance. 1. What patient resides in California? What is the patient number? Sofia Yakaria Pallares is the patient who resides in California. Her patient number is 10259. 2. Who is the provider of Sofia Yakaria Pallares? What credentials does her provider have? Ruth Ann Raymond is the patient’s provider. Ruth Ann Raymond has her MD license. 3. What patient was seen on 11/05/2010? What is the patient’s date of birth? John Peters with a date of birth 05/25/1965 was seen on 11/058/2010. 4. What date and time did patient #1298 visit the doctor’s office? What is the patient’s name and date of birth? Lucy Ann Johnson, date of birth 06/12/1975 visit the doctor’s office on 06/04/2011 at 17:15 (5:15pm). 5. What patient lives in 1704 N. Atlantic Ave Ontario, AZ 85320? What is its encounter number? John Peters lives at 1704 N. Atlantic Ave Ontario, AZ 85320. His encounter number is 111218. Patient Info Table Pat# Last_Name First_Name Middle_Name Birthdate 10259 Pallares Sofia Yakaria 9/18/1985 30528 Peters John 5/25/1965 1298 Johnson Lucy Ann 6/12/1975 Patient Address Table Pat# Address City State...
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...and implemented more frequently by health care providers throughout the United States. This technology may include Electronic Health Records (EHR) or Electronic Medical Records (EMR). The shift towards implementing Electronic Health Records has a significant influence on the quality of care provided by health care providers; however, some providers still stick to the basic paper documentation due to skepticism and disregard the benefits to adopting new technologies. Many questions arise when a health care provider is interested in adopting EHR’s, such as why adopt EHR’s? What are the benefits of EHR’s in relation to paper documentation? What steps need to be taken in order to adopt and implement EHR’s? What barriers will be encountered during the decision making process and how will these barriers be addressed? A health practice interested in adopting and implementing an EHR system must establish priorities, identify potential risks and how to avoid or overcome these risks, outweigh the pros and cons, set goals, and adhere to strict guidelines to ensure adopting a successful system. The terms Electronic Health Records (EHR) and Electronic Medical Records (EMR) are often used interchangeably by health care providers when in fact there is a subtle difference between EHRs and EMRs. Electronic Medical Records and Electronic Medical Records are both digital versions of a patient’s medical history and information; however EMRs are designed to communicate within one specific...
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...information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis. Compliance Status The Nightingale Community Hospital current compliance status is not meeting the standards of the Joint Commission. RC.01.01.01 The hospital has just an admission orders form that does not define the components of a complete medical record. The admission orders form does not contain the unique patient’s identification. It has just the patient name, and two or more people may have the same name. Wrong patient identification may be one of the reasons why there have been errors labeling patient specimens. Although there is a place on the form to identify consults, there is no justification for the consult on the patient’s chief compliant and no admitting diagnoses recorded. The medical record on hand does not contain information needed to justify the patient’s care, treatment and services. For example, there is no reason given for intake/output nor is there route for the intake (feeding tube, IV, or PO), or output (urinal, foley, stool, or colostomy). The hospital is not in compliance because the medical record does not contain results of any type of diagnostic testing that support the course and result of the patient’s care, treatment and services. The hospital does not promote continuity of care among providers. Although there is a case management consult that...
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...associated with accessing patient medical records, duplicating services, data organization, order entry and many other problems one may face in the healthcare industry. In my most recent conversation with a Licensed Practical Nurse at the local health department in Northeastern North Carolina, I was astonished to learn that this region, serving 12 counties, is still currently using paper file folders for recordkeeping of all of patient medical records. Although they have begun the process of seeking to move toward an electronic health records (EHR) application system, it is a very slow process as they are currently keeping records on both paper files and the newly EHR system. By implementing the EHR system, access to medical records will be available to all persons involved with caring for each patient while alleviating the endless paper trail associated with medical records. Garets and Davis (2006) report that many people in the healthcare industry and the government confuse the terms electronic medical record (EMR) and electronic health record (EHR). Garets and Davis (2006) proposed the following definition for the two interchangeably terms: The EMR is an application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. The data in the EMR is the legal record of what happened to the patient during their encounter at...
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...where electronic records and shared information will bring a better experience for our patients. III. Mission b. The medical center of Lewisville promises quality service with our computerized system that will make it easier for patients to request information and register at the facility. IV. SWOT Analysis (Strengths, Weaknesses, Opportunities and Threats) c. The strengths are that we have a expert team and plan in place to set the structure. d. Weakness is that there are a number of departments and we need to be sure to connect so data is shared and retrieved easily. e. Opportunities are that we do have the expertise and the chance to look at local facilities with similar information systems. f. Possible threats are that we wouldn’t be able to start off with the ease and flow in the initial stage. V. Plan Objectives g. To complete a rough run in 3 months time so we can evaluate our plan VI. Tasks and Timelines VII. Evaluate each department system at the end of two months VIII. Budgeting and Resources Executive summary The purpose of this strategic plan is to create an information system for the Medical center of Lewisville that will integrate current technology in the information structure of the facility. It is the vision of the medical center to bring state of the art information system where electronic records and shared information will bring a better experience for our patients. It is our...
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...C156 Advanced Information Management– Task 1 A2. Analysis of Technology Two organizations migrating to a common health information system would need a system that meets current regulatory requirements, meets the needs of the combined organization and their practice environment. The implementation of a common health information system would require an interdisciplinary group of forward thinking innovators, and an interoperable electronic medical record system that includes standard nursing terminology. The technology needed in this scenario that would make this combination successful consist of network security measures to ensure security of protected health information under the federal requirements of HIPPA and HITECH. The use of emerging technology such as cellphones, tablets and remote technology should also be included in the discussions of creating a telehealth system that would accommodate both of the combining organizations. Telehealth not only includes communication between patients and healthcare providers, but also communication between healthcare providers in both of the combining organizations. Video conferencing can save healthcare providers time and money by allowing them to collaborate with one another without being physically near one another. A3. Identification of Team The interdisciplinary team on the project committee will consist of four team members. Team member A would be the project team lead in which I would nominate myself...
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...devices used by the nursing staff could be integrated into the management system for better quality care D. Security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and the Health Insurance Portability and Accountability Act (HIPPA) requirements impact the use of the systems E. How the new system can affect healthcare cost F. The benefits these new systems can offer to patient care and nursing care delivery with a recommendation and justification of the system the hospital should put in place In today’s modern healthcare environment it is important to provide a variety of technology based resources to nurses and other providers to ensure productivity and efficiency are maximized. This requires an effective understanding of available computerized management systems and what resources are available to ensure continued effective, efficient, quality care to patients. Keeping that perspective in mind while creating a technologically advanced environment in which to deliver that care is critical and of vital importance to maximize resources while providing a solid technology platform. The utilization of electronic medical records and nursing documentation systems to ease the burden of paper based records, as well as the space required to store those records in a desirable manner is critical for an organization to sustain its capacity to provide high quality health care. This discussion will explore...
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...BUGANDA ROYAL INSTITUTE OF BUSINESS AND TECHINICAL EDUCATION - MENGO AUTOMATED IMMUNISATION RECORDS MANAGEMENT SYSTEM A CASE STUDY OF NSANGI HEALTN CENTER III A RESEARCH REPORT BY NAMATOVU ANGELLA BR/DCS/8045/11 A RESEARCH REPORT SUBMITTED TO THE DEPARTMENT OF COMMUNICATION AND EDUCATION IN PARTIAL FULFILMENT FOR THE AWARD OF DIPLOMA IN COMPUTER SCIENCE OF BUGANDA ROYAL INSTITUTE OF BUSINESS AND TECHNICAL EDUCATION JULY 2013 DECLARATION I hereby declare that this research which submitted to the department of communication and education of Buganda Royal institute is my original work and it is and it has never been submitted to any other degree/diploma award institute. Students Name: NAMATOVU ANGELLA Reg No:BR/DCS/8045/11 Date:___________________________ Approval I approve that this research report has been under my supervision and it is ready for Submission to the academic council of Buganda Royal Institute. Supervisor’s Name: Mr. SSekuwanda Henry Signature: ____________________________ Date: ___/07/2013 DEDICATION I dedicate this research report firstly my mother who has sacrificed whatever My siblings and my friends at Buganda Royal Institute for both moral and financial support they have provided. May the almighty God Reward them accordingly. ACKNOWLEDGEMENT I would like to acknowledge this piece of work most especially...
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...Department of Gary Job Corps Center Definition: Healthcare industry is being faced by a major threat that is misuse of patient health information. To protect the patient and their families during their job transition or the unemployment period and to protect the patient health information from being misused the U.S Congress ratified HIPAA i.e. Health Insurance Portability and Accountability Act. HIPAA protects patients and their families in times of their unemployment by providing them with Health Insurance at that particular time. (Wikipedia, 2011) The area of study this research addresses is the health care industry and the processes within. Healthcare industry is one industry that is always successfully operational because human being is exposed to the threat of illness every second. Since health care industry is always operational, the competition within the industry is extremely high. The competition is not only about who provides the best services, but it is also about who provides the best protection to the patients in terms of managing their information as well as protecting them in times of need. The subject under consideration is to study the health department of Gary Job Corps Center and develop a procedure that is compliant with HIPAA. The procedure in focus will be the management of patient health information and its security maintenance in compliance with HIPAA. The proposed solution will be given in consideration of the basic...
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...pre-licensure nursing curriculum. Provide two examples of teaching strategies utilizing the following: Electronic health record as a learning tool A teaching strategy from the QSEN project specifying a specific student assignment relevant to nursing informatics. Conclude your discussion with a well-developed reflection on the significance of healthcare informatics to 21st century nursing education. In response to the Institution of Medicine call to improve the quality of healthcare the Quality and Safety Education for Nurses (QSEN) initiative was started. The QSEN initiative consisted of the development of quality and safety competencies that serve as a resource for nursing faculty to integrate contemporary quality and safety content into nursing education. Nurses are on the front line of patient safety. It is important for the nursing profession to realize all the benefits healthcare informatics can offer to ease their jobs and improve patient safety. Introducing health care informatics into the nursing curriculum will prepare the student for new and innovative technologies on the horizon in the healthcare community. Safety benefits are consistent with the use electronic health record. If electronic medical records are being used by the nurse, the physician is using them as well. Implementing EMR has solved the challenged of illegible handwriting that has led to increase medical errors. Another benefit of the electronic medical record is that it often works in conjunction...
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...Electronic Medical Records and Health Information Technology Gina Martin INF103: Introduction to Computer Literacy Dr. Alex Lazo May 6, 2013 Electronic Medical Records and Health Information Technology Healthcare in America has been an extremely political and controversial subject these past few years. The subject became a political discussion when President Barack Obama proposed a totally new form of healthcare called, “Obamacare”. This new healthcare plan would be affordable to everyone in the United States. This plan would offer a high quality of care regardless of your financial status or situation. This healthcare plan would cover everyone, from part-time as well as full-time employees, and even some per diem workers. When the President signed his healthcare package into law, it had several stipulations that employers were required to follow: they were required to offer healthcare to all employees, and that healthcare had to be affordable to the employee. If employees do not purchase some type of healthcare plan, once offered, they may suffer a tax penalty when filing income taxes. The big controversial part come about when President Obama stated, “That there will be no more free rides for the cost of healthcare for the upper tier, highly paid working government executives and their families that could afford to pay for the cost of their healthcare premiums all along These people who have in the past billed their costs of healthcare to the taxpayers...
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...Improving Local Health Care Travoria Freeman Think back on the last time you accessed health care services in your community and make recommendations for incorporating unapplied telecommunications concepts that would have improved your last visit. Provide specific examples to support your response. It is not unreasonable for a patient to expect particular services from their healthcare providers. What happens when you are traveling and have to make a trip to the emergency room, will your doctor at home get the information from that visit? Health information recorded in paper format makes these tasks very hard, if not impossible. Luckily, there is a growing movement to transform that, using information management and information technology. The use of this type of equipment allows for "high-quality, safe, and competent care. Society today is constantly changing. Society changes jobs, location of residence, and doctors often. While society speaks of a medical structure American medicine is disorganized: it lacks standards, measures, and the ability to exchange information that constitutes a true structure. The medical industry has taken to every kind of clinical technology; from digital thermometers to CT scanners. However, the implementation of information management and information technology in the medical industry falls behind the rest of our economy. Health informatics is best described as the...
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