The Paper Medical Record
|
|
|
- Randolph Hines
- 8 years ago
- Views:
Transcription
1 The Paper Medical Record alphabetic filing Audit Caption continuity of care direct filing system indirect filing system numeric filing Obliteration Chapter 14 lesson 1 alphanumeric augment chronologic order dictation gleaned microfilm objective information OUTfolder Journal question: Why is proper filing and management of medical records so important with regard to time management in the medical office? Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1
2 Introduction Medical records management systems are only as good as the ease of retrieval of the data in the files. Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2
3 Objectives: Define, spell, and pronounce the terms listed in the vocabulary State several reasons accurate medical records are important Explain who owns the medical record Explain how to establish and organize a patient medical record Explain the difference between a traditional medical record and a problem-oriented medical record. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3
4 Objectives: Identify systems for organizing medical records Differentiate between subjective and objective information Describe various types of information kept in the medical record Explain how to make additions to a medical record Discuss correction of an entry in a patient s record. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4
5 This chapter will examine: Reasons for keeping accurate records Ownership of records Differences among types of records Differences among types of information Making corrections in the record Filing procedures and systems Forms found in medical records Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5
6 Why Medical Records Are Important Assist the physician in providing the best possible care to the patient Offer legal protection to those who provide care to the patient Provide statistical information that is helpful to researchers Vital for financial reimbursement Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6
7 Ownership of the Medical Record The maker, who initiated and developed the record, owns the physical medical record. The maker can be a physician or a medical facility. Patients have a right of access to the information in the record. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7
8 Points to Remember Medical records must be kept confidential and in a secured, locked location. The record should never leave the medical facility in which it originated. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8
9 Creating an Efficient Medical Record System The system should: provide for easy retrieval be organized and orderly contain information that is completely legible contain accurate information show information that is easily understood and grammatically correct Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9
10 Types of Records Paper-based medical records Computer-based medical records Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10
11 Disadvantages of Paper-Based Medical Records Only one person can use the record at a time, unless multiple people are crowding around the same record. Items can be easily lost or misfiled or can slip out of the record if not securely fastened. The record itself can be misplaced or be in a different area of the facility when needed. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11
12 Advantages of Computer-Based Medical Records More than one person can use the record at a time. Information can be accessed in a variety of physical locations. Records can often be accessed from another city or state. Complete information is often available in emergency situations. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12
13 Organization of the Medical Record Source-oriented records Problem-oriented records Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13
14 Source-Oriented Medical Records Traditional method of keeping patient records Observations and data are cataloged according to their sources Forms and progress notes are filed in reverse chronologic order Separate sections are established for laboratory reports, x-ray films, radiology reports, etc. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14
15 Problem-Oriented Medical Records Divides records into four bases: 1. Database 2. Problem list 3. Treatment plan 4. Progress notes Courtesy Bibbero Systems, Petaluma, Calif. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15
16 Database Includes: Chief complaint Present illness Patient profile Review of systems Physical examination Laboratory reports Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16
17 Problem List Numbered and titled list of every problem the patient has that requires treatment May include social and demographic troubles as well as medical and/or surgical notes Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17
18 Treatment Plan Includes: Management Additional workups needed Therapy Each plan is titled and numbered with respect to the problem. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18
19 Progress Notes Structured notes are numbered to correspond with each problem number. Progress notes follow the SOAP approach. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19
20 SOAP Approach to Progress Notes SOAP acronym S Subjective impressions O Objective clinical evidence A Assessment or diagnosis P Plans for further studies, treatment, or management Optional E Evaluation or Education R Response Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20
21 CHEDDAR C Chief Complaint H History E Examination D Details (of problem and complaints) D Drugs and dosages A Assessment R Return visit Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21
22 Review List three classifications of files. Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22
23 Review List three classifications of files. Answer: Alphabetic, numeric, alphanumeric Copyright 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23
Health Information Technology & Management Chapter 4 ORGANIZATION, STORAGE, AND MANAGEMENT OF HEALTH RECORDS BY : NOHA ALAGGAD
Health Information Technology & Management Chapter 4 ORGANIZATION, STORAGE, AND MANAGEMENT OF HEALTH RECORDS BY : NOHA ALAGGAD PAPER CHARTS Consist of one or more file folders containing handwritten notes,
Introduction to Health Insurance
Chapter 2 PART 2 of 2 Introduction to Health Insurance Copyright 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. 1 Healthcare Documentation Documentation is the systematic, logical, and consistent
Health Information Technology and Management
Health Information Technology and Management 6 CHAPTER Organization, Storage, and Management of Health Records Pretest (True/False) Professional responsibilities often require an individual to move beyond
Charting Reporting and Recording Dr. Karima Elshamy Faculty of Nursing Mansoura University Egypt Learning Objectives: Define the following terminology chart, charting, patient record Discuss the purpose
Records Management. Objectives. With the person sitting next to you, Presented by: Rachel Martin. After this workshop, you ll be able to:
Records Management Presented by: Rachel Martin Objectives After this workshop, you ll be able to: Implement a new records management system Perfect filing techniques Streamline and improve records management
LEARNING OBJECTIVES TERMINOLOGIES
Nursing Documentation Dr. Ali D. Abbas/ Instructor, Fundamentals of Nursing Department, College of Nursing, University of Baghdad, ali_dukhan@yahoo.com LEARNING OBJECTIVES After mastering the contents
HIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice
Mona Osman MD, MPH, MBA
Mona Osman MD, MPH, MBA Objectives To define an Electronic Medical Record (EMR) To demonstrate the benefits of EMR To introduce the Lebanese Society of Family Medicine- EMR Reality Check The healthcare
MCCANN TECHNICAL SCHOOL MEDICAL ASSISTING PROGRAM 70 Hodges Cross Road North Adams, MA 01247
MCCANN TECHNICAL SCHOOL MEDICAL ASSISTING PROGRAM 70 Hodges Cross Road North Adams, MA 01247 COURSE SYLLABUS Spring Semester NAME OF COURSE: CREDITS: INSTRUCTOR: METHODOLOGY: MA 206 MEDICAL OFFICE ADMINISTRATION
Purposes of Patient Records
CHAPTER 6 Documentation 1 Slide 1 Purposes of Patient Records Five Basic Purposes for Written Records Written communication Permanent record for accountability Legal record of care Teaching Research and
MEDICAL MUTUAL Self-Assessment Form
MEDICAL MUTUAL Self-Assessment Form PURPOSE: The purpose of the self-assessment form is to highlight those areas within the non-clinical aspect of office practice including documentation of medical records,
HIM 111 Introduction to Health Information Management HIM 135 Medical Terminology
HIM 111 Introduction to Health Information Management 1. Demonstrate comprehension of the difference between data and information; data sources (primary and secondary), and the structure and use of health
Electronic Health Record
Electronic Health Record Course Health Science Unit II Communication Essential Question What is an electronic health record? TEKS 130.204 (c) 4A, 4B, 5A, 5B Prior Student Learning Basic understanding of
CHAPTER 1 MEDICAL RECORDS MANAGEMENT
LEARNING OBJECTIVES In this PowerPoint presentation, we will learn about: How has medical records developed over the years and the use of medical records? How are medical records prepared, maintained,
Health Information Technology & Management Chapter 2 HEALTH INFORMATION SYSTEMS
Health Information Technology & Management Chapter 2 HEALTH INFORMATION SYSTEMS INFORMATION SYSTEM *Use of computer hardware and software to process data into information. *Healthcare information system
GUIDELINE No. 117 THE PHYSICIAN MEDICAL RECORD*
Purpose of Medical Records: GUIDELINE No. 117 THE PHYSICIAN MEDICAL RECORD* The physician s medical record is a reflection of the interaction between a physician and a patient. For each interaction the
By Karen K. Davis, MA, CPHRM, NORCAL Mutual, a member of the NORCAL Group
HIGH-RISK ISSUES ASSOCIATED WITH LAWSUITS AND WHAT TO DO ABOUT THEM By Karen K. Davis, MA, CPHRM, NORCAL Mutual, a member of the NORCAL Group What are some of the riskiest areas associated with practicing
The Complete Medical Record and Electronic Charting
Name Date Score C H A P T E R 3 The Complete Medical Record and Electronic Charting FIELD RELEVANCY AND BENEFITS The medical record is the most important record kept in the medical office. Whether you
HEALTH DEPARTMENT BILLING GUIDELINES
HEALTH DEPARTMENT BILLING GUIDELINES Acknowledgement: Current Procedural Terminology (CPT ) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
HIGH-RISK ISSUES ASSOCIATED WITH LAWSUITS AND WHAT TO DO ABOUT THEM
HIGH-RISK ISSUES ASSOCIATED WITH LAWSUITS AND WHAT TO DO ABOUT THEM By Karen K. Davis, MA, CPHRM, Risk Management Research Specialist What are some of the riskiest areas associated with practicing medicine
What is your level of coding experience?
The TrustHCS Academy is dedicated to growing new coders to enter the field of medical records coding while also increasing the ICD-10 skills of seasoned coding professionals. A unique combination of on-line
Administrative Guide
Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide Doc#: PCA15026_20141201 UHCCommunityPlan.com Welcome to UnitedHealthcare This administrative
The file and the documentation should create a clean chronological record of the patient and their interactions with the provider.
Documentation and Coding Guidelines for Athletic Trainers Table of Contents What is documentation and why is it important? Documentation and SOAP What do payers want and why? General guidelines of medical
36 Interviewing the Patient, Taking a History, and Documentation
CHAPTER 36 Interviewing the Patient, Taking a History, and Documentation Learning Outcomes 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Implement the procedure for conducting
Laboratory Information Management Systems. Presented By: Happy Mashigo & Vuyiswa Kenke
Laboratory Information Management Systems Presented By: Happy Mashigo & Vuyiswa Kenke Welcome Welcome to the Laboratory Information Management Systems Module 2 Module Objectives At the end of this module,
COM Compliance Policy No. 3
COM Compliance Policy No. 3 THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: 3 UIC College of Medicine DATE: 8/5/10 Chicago, Illinois PAGE: 1of 7 UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE CODING AND DOCUMENTATION
a) Each facility shall have a medical record system that retrieves information regarding individual residents.
TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1810 RESIDENT RECORD REQUIREMENTS
Provider Manual Section 4.0 Office Standards
Provider Manual Section 4.0 Office Standards Table of Contents 4.1 Appointment Scheduling Standards 4.2 After-Hours Telephone Coverage 4.3 Member to Practitioner Ratio Maximum 4.4 Provider Office Standards
CAROLINAS REHABILITATION
CAROLINAS REHABILITATION CURRENT LANGUAGE ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) New Language ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) ARTICLE II
Patient Progress Note & Dictation Standard
Objective: The patient progress note serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's
10/23/2010. Objectives. Coding Process. What is ICD-9-CM coding? HCPCS. What is CPT-4? Provide a basic understanding of the coding process
Objectives Medical Coding and Billing HCMT 200 Provide a basic understanding of the coding process Understand the importance of complete, accurate documentation to the coding process Learn the benefits
Medical Billing & Coding Catalog Course Description
Medical Billing & Coding Catalog Course Description Effective 6/10/2011 Medical Billing & Coding Course Description Educational Objectives: American School of Technology s Medical Billing and Coding program
MEDICAL MANAGEMENT PROGRAM LAKELAND REGIONAL MEDICAL CENTER
MEDICAL MANAGEMENT PROGRAM LAKELAND REGIONAL MEDICAL CENTER Publication Year: 2013 Summary: The Medical Management Program provides individualized care plans for frequent visitors presenting to the Emergency
NCI-Frederick Safety and Environmental Compliance Manual 03/2013
E-1. Records Management I. Scope The Records Management Office maintains a comprehensive records management system meeting regulatory and contractual requirements ensuring documentation is readily accessible.
Records Management Procedure Procedure No.: 6701 PR1
Records Management No.: 6701 PR1 Policy Reference: 6701 Category: Records Management Department Responsible: Records Management and Privacy Current Approved Date: 2011 Dec 15 Objectives This procedure
Formulary Management
Formulary Management Formulary management is an integrated patient care process which enables physicians, pharmacists and other health care professionals to work together to promote clinically sound, cost-effective
Continuation. Documentation may be the least favorite part of your job but it's also one of the most important aspects. Incomplete or improper poses
Documentation Objectives Define the documentation concept Discuss the purpose of documentation in the patient record. Describe factors that impact on documentation. Discuss the "who, what, when, where,
Health Information Technology Backgrounder
Health Information Technology Backgrounder An electronic health record (EHR) is defined by the National Alliance for Health Information Technology as an electronic record of health-related information
Sample Assignment 1: Workflow Analysis Directions
Sample Assignment 1: Workflow Analysis Directions Purpose The Purpose of this assignment is to: 1. Understand the benefits of nurse workflow analysis in improving clinical and administrative performance
Chapter 15 The Electronic Medical Record
Chapter 15 The Electronic Medical Record 8 th edition 1 Lesson 15.1 Introduction to the Electronic Medical Record Define, spell, and pronounce the terms listed in the vocabulary. Discuss the presidential
HIPAA and Network Security Curriculum
HIPAA and Network Security Curriculum This curriculum consists of an overview/syllabus and 11 lesson plans Week 1 Developed by NORTH SEATTLE COMMUNITY COLLEGE for the IT for Healthcare Short Certificate
Medical Information Systems
Medical Information Systems Introduction The introduction of information systems in hospitals and other medical facilities is not only driven by the wish to improve management of patient-related data for
MEDICAL OFFICE ASSISTANT. Source: Applied Education Systems Website: Healthcenter21.com. Unit Lesson MEDICAL OFFICE ASSISTANT TESTS
MEDICAL OFFICE ASSISTANT Source: Applied Education Systems Website: Healthcenter21.com WEEK 1-2 MEDICAL OFFICE ASSISTANT Introduction to MOA The Medical Office Assistant List general responsibilities of
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention Division of Tuberculosis Elimination Public
PROBLEM-ORIENTED MEDICAL RECORD (POMR)
PROBLEM-ORIENTED MEDICAL RECORD (POMR) The POMR as initially defined by Lawrence Weed, MD, is the official method of record keeping used at Foster G. McGaw Hospital and its affiliates. Many physicians
Medical Record Documentation Standards
Medical Record Documentation Standards Medical Record Documentation Standards and Performance Measures Compliance with the Standards is monitored as part of our Quality Improvement Program. Practitioner
II. MUNICIPAL RECORDS MANAGEMENT
II. MUNICIPAL RECORDS MANAGEMENT Why Records Management? The administration of local government has grown steadily more complex in recent times. Public demands for increased efficiency, improved services,
Johns Hopkins HealthCare LLC Practitioner Office Site Evaluation Form
Page1 Initial Credentialing: Recredentialing: New Location: C&G: Date of review: / / Provider Name: Practice Name: Tax ID#: Vistar ID# County: Address: Phone #: Fax# Email: Names and specialties of other
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION Hospital Policy Manual Purpose: To define the components of the paper and electronic medical record
NHS SCOTLAND PERSONAL HEALTH RECORDS MANAGEMENT POLICY FOR NHS BOARDS
INFORMATION GOVERNANCE RECORDS MANAGEMENT GUIDANCE NOTE NUMBER 002 NHS SCOTLAND PERSONAL HEALTH RECORDS MANAGEMENT POLICY FOR NHS BOARDS Guidance Note 002 1 1 HEALTH RECORDS MANAGEMENT POLICY 1.1 Introduction
INDEPENDENT MEDICAL EXAMINATION. Dr. Jeffery Luther
INDEPENDENT MEDICAL EXAMINATION Dr. Jeffery Luther What is an Independent Medical Exam? Objective and impartial medical exam Requested by workers compensation insurer or self insured provider Conducted
Running Head: WORKFLOW ANALYSIS 1. Workflow Analysis of a Primary Care Clinic Before and After Implementation of an Electronic Health Record
Running Head: WORKFLOW ANALYSIS 1 Sample Answer to Workflow Analysis Assignment Workflow Analysis of a Primary Care Clinic Before and After Implementation of an Electronic Health Record There are numerous
Current Procedural Terminology CPT 2012 Standard E, American Medical Association, Copyright 2011. ISBN: 978-1-60359-567-4.
HIT 185: Basic CPT Coding (3 Credits) Course Description An introduction to the basic coding guidelines of the Current Procedural Terminology (CPT) nomenclature. Students will learn the format of CPT and
Professional Practice Medical Record Documentation Guidelines
Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating
Security of Archives in the Custody of the NT Archives Service
Northern NT GOVERNMENT Territory ARCHIVES ADVICE Archives 5 Service Archives Advice 5 Security of Archives in the Custody of the NT Archives Service August 2007 For information and advice, please contact
Forms designed to collect this information will help staff collect all pertinent information.
1 CPT AUDIT TOOL INSTRUCTIONS The Nursing Consultants from the Public Health Nursing and Professional Development Unit based on multiple Evaluation & Management audits across the state have developed these
Comprehensive Health Insurance Billing Coding Reimbursement
Comprehensive Health Insurance Billing Coding Reimbursement SECOND EDITION CHAPTER 17 Refunds, Follow-up, and Appeals Key Terms and Abbreviations administrative law judge (ALJ) hearing documentation Employee
North Carolina Medicaid Special Bulletin
North Carolina Medicaid Special Bulletin An Information Service of the Division of Medical Assistance Please visit our Web site at www.ncdhhs.gov/dma July 2007 ATTENTION: All Providers Notice of Change
Content Sheet 13-1: Overview of Customer Service
Content Sheet 13-1: Overview of Customer Service Role in quality management system This module will describe basic elements that are essential for developing an effective customer service program. Customer
AHIMA Curriculum Map Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee February 2011
AHIMA Curriculum Map Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee February 2011 HIM Associate Degree Entry-Level Competencies (Student Learning Outcomes)
B. Clinical Data Management
B. Clinical Data Management The purpose of the applications of this group is to support the clinical needs of care providers including maintaining accurate medical records. Ideally, a clinical data management
Lesson 2: Health Professions
Glossary 1. Bachelor s Degree: a 4-year degree from a college or university 2. Certification: some jobs require you to complete a training program or pass an exam to show that you have the knowledge to
What you should know about Data Quality. A guide for health and social care staff
What you should know about Data Quality A guide for health and social care staff Please note the scope of this document is to provide a broad overview of data quality issues around personal health information
CODING. Neighborhood Health Plan 1 Provider Payment Guidelines
CODING Policy The terms of this policy set forth the guidelines for reporting the provision of care rendered by NHP participating providers, including but not limited to use of standard diagnosis and procedure
POLICY and PROCEDURE. TITLE: Documentation Requirements for the Medical Record. TITLE: Documentation Requirements for the Medical Record
POLICY and PROCEDURE TITLE: Documentation Requirements for the Medical Record Number: 13289 Version: 13289.1 Type: Administrative - Medical Staff Author: Joan Siler Effective Date: 8/16/2011 Original Date:
HI-1018: The Electronic Health Record
Course Introduction Course Introduction HI-1018: The Electronic Health Record 6m Chapter 01 - Introduction Introduction History Medical Record History Medical Records Purpose Paper Electronic EMR versus
Fundamentals. of Records & Information. Management
Fundamentals of Records & Information Management Records & Information Management Two Major Objectives: To manage the creation, growth, duplication, maintenance, retention and disposition of records. (Records
RARITAN VALLEY COMMUNITY COLLEGE ACADEMIC COURSE OUTLINE INTRODUCTION TO HEALTH INFORMATION TECHNOLOGY HITC - 105
RARITAN VALLEY COMMUNITY COLLEGE ACADEMIC COURSE OUTLINE INTRODUCTION TO HEALTH INFORMATION TECHNOLOGY HITC - 105 I. Basic Course Information A. Course Number and Title: HITC105 Introduction to Health
Questions and answers for custodians about the Personal Health Information Privacy and Access Act (PHIPAA)
Questions and answers for custodians about the Personal Health Information Privacy and Access Act (PHIPAA) This document provides answers to some frequently asked questions about the The Personal Health
Guidance on information governance for health and social care services in Ireland
Guidance on information governance for health and social care services in Ireland About the Health Information and Quality Authority The (HIQA) is the independent Authority established to drive continuous
THE IMPORTANCE OF COMPREHENSIVE NOTES AND RECORDS by: Ryan A. Murray, Oatley Vigmond Personal Injury Lawyers LLP
THE IMPORTANCE OF COMPREHENSIVE NOTES AND RECORDS by: Ryan A. Murray, Oatley Vigmond Personal Injury Lawyers LLP Introduction Comprehensive clinical notes and records are an important part of patient care.
NHS LANARKSHIRE HEALTH RECORDS POLICY Management and Maintenance, Security, Storage, Distribution and Retention of Health Records
NHS LANARKSHIRE HEALTH RECORDS POLICY Management and Maintenance, Security, Storage, Distribution and Retention of Health Records Author: Responsible Lead Executive Director: Endorsing Body: Governance
E/M Learning Tips INTRODUCTION TO EVALUATION. Introduction to Evaluation and Management (E/M) Coding for the Child and Adolescent Psychiatrist
INTRODUCTION TO EVALUATION AND MANAGEMENT (E/M) CODING FOR THE CHILD AND ADOLESCENT PSYCHIATRIST Benjamin Shain, MD, PhD David Berland, MD Sherry Barron-Seabrook, MD Copyright 2012 by the American Academy
Disclaimer CODING 101 BOOT CAMP CODING SEMINAR FOR NEW PHYSICIANS
CODING 101 BOOT CAMP CODING SEMINAR FOR NEW PHYSICIANS AND STAFF Chicago Dermatological Society January 26, 2013 Presented by Joy Newby, LPN, CPC, PCS Newby Consulting, Inc. 5725 Park Plaza Court Indianapolis,
Glossary of Frequently Used Billing and Coding Terms
Glossary of Frequently Used Billing and Coding Terms Accountable Care Organization (ACO) Accounts Receivable Reports All Inclusive Fees Allowances and Adjustments Capitation Payments Care Coordination
Medical Administrative Aspects Course Outcome Summary
Medical Administrative Aspects Course Outcome Summary Course Information Description Provides an introduction to the administrative skills needed for a medical office. Students learn how to maintain medical
Health Information. Technology and Cancer Information Management. Health Information Technology & Cancer Information Management 363
Health Information Technology & 363 Health Information Technology and Cancer Information Management Opportunities in the health information field have expanded with changes in health care delivery, utilization
The Principles of Document Control By Dave Baldwin
The Principles of Document Control By Dave Baldwin The Out of Control Syndrome Organizations create documents daily. They are used to convey new ideas, provide direction, give instructions, describe processes,
A.4.2. Challenges in the Deployment of Healthcare Information Systems and Technology
A.4.2. Challenges in the Deployment of Healthcare Information Systems and Technology In order to support its constituent enterprise in Latin America and the Caribbean and deliver appropriate solutions,
TEMPLATE DATA MANAGEMENT PLAN
TEMPLATE DATA MANAGEMENT PLAN ICRIN (QM sub group) Version: XX Date: XXXXXXX Page 1 of 6 1.0 Document Ownership The Data Management Plan (DMP) will be initiated and subsequently owned by the Data Manager
Medical Coding and Billing Specialist Course Description
Medical Coding and Billing Specialist Course Description EDUCATIONAL OBJECTIVES American School of Technology s Medical Coding and Billing Specialist program is an academic program that prepares graduates
Knowledge Clusters (Curricular Components) HIM Associate Degree Entry-Level Competencies (Student Learning Outcomes) Notes
2011 AHIMA Curriculum Competencies and Knowledge Clusters Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee HIM Associate Degree Entry-Level Competencies (Student
AHIMA Curriculum Map Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee February 2011
HIM Associate Degree Entry Level Competencies (Student Learning Outcomes) I. Domain: Health Data Management A. Subdomain: Health Data Structure, Content and Standards 1. Collect and maintain health data
DQA Hospital Q&A Page 1 of 24 Created on 03/10/2010 1:15:00 PM
DQA Hospital Q&A Page 1 of 24 Created on 03/10/2010 1:15:00 PM 1. Is there a specific regulation or an interpretation of a regulation, in which soiled utility room doors must be locked? No. There is not
Reimbursement Policy General Coding Section Policy Number: RP - General Coding - 005 Unlisted Procedure Code Effective Date: June 1, 2015
Status Active Reimbursement Policy Section: General Coding Section Policy Number: RP - General Coding - 005 Unlisted Procedure Code Effective Date: June 1, 2015 Unlisted Procedure Code Policy Description:
2015 HSC Business Services Marking Guidelines
205 HSC Business Services Marking Guidelines Section I Multiple-choice Answer Key Question Answer B 2 B 3 C 4 B 5 D 6 A 7 C 8 B 9 D 0 A A 2 C 3 A 4 C 5 A Section II Question 6 (a) Demonstrates a sound
Lesson 1 The Exciting World of Medical Transcription
Lesson 1 The Exciting World of Medical Transcription Step 1 Learning Objectives for Lesson 1 When you have completed the instruction in this lesson, you will be trained to do the following: Explain how
MEDICAL CENTER POLICY NO. 0094. A. SUBJECT: Documentation of Patient Care (Electronic Medical Record)
Clinical Staff Executive Committee MEDICAL CENTER POLICY NO. 0094 A. SUBJECT: Documentation of Patient Care (Electronic Medical Record) B. EFFECTIVE DATE: April 1, 2012 (R) C. POLICY: The University of
Verbal and Non-verbal Communication. It takes two to communicate!
Verbal and Non-verbal Communication It takes two to communicate! Four Elements of Communication Sender-generates information, thoughts, ideas or feelings Message- generated by sender and responded to by
Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
The Complete Medical Record and Electronic Charting
C H A P T E R The Complete Medical Record and Electronic Charting Chapter Outline The Medical Record Important Uses of the Medical Record Medical Record Formats Source-Oriented Medical Record (SOMR) Problem-Oriented
In the event of any inconsistency between this standard and any legislation that governs the practice of physiotherapists, the legislation governs.
Record Keeping College publications contain practice parameters and standards which should be considered be all Ontario physiotherapists in the care of their patients and in the practice of the profession.
SERIES NUMBER 6565 SPECIFICATION
STATE OF OHIO (DAS) CLASSIFICATION CLASSIFICATION SERIES Nurse Practitioner SERIES NUMBER 6565 SPECIFICATION MAJOR AGENCIES All Agencies EFFECTIVE 12/14/2014 SERIES PURPOSE The purpose of the nurse practitioner
Institute for Advanced Study Shelby White and Leon Levy Archives Center
Institute for Advanced Study Shelby White and Leon Levy Archives Center Managing Electronic Records - Recommendations for Institute Staff File Management: Guidelines & Policies Which files are considered
Mississippi Medicaid. Provider Reference Guide. For Part 220. Radiology Services
Mississippi Medicaid Provider Reference Guide For Part 220 Radiology Services This is a companion document to the Mississippi Administrative Code Title 23 and must be utilized as a reference only. Table
Copyright 2013 wolfssl Inc. All rights reserved. 2
- - Copyright 2013 wolfssl Inc. All rights reserved. 2 Copyright 2013 wolfssl Inc. All rights reserved. 2 Copyright 2013 wolfssl Inc. All rights reserved. 3 Copyright 2013 wolfssl Inc. All rights reserved.
OUTPATIENT HEALTH RECORD FORMAT. 2. Consent to Minor Surgical or Invasive Procedure. 3. Consent for Disclosure of Information
OUTPATIENT HEALTH RECORD FORMAT The Health Record is arranged in reverse chronological order from the current date to the date of admission. SIDE I: Administrative Section 1. Refusal of Treatment 2. Consent
Great-West G R O U P. Short Term Disability Income Benefits Employee s Statement
Great-West G R O U P Short Term Disability Income Benefits Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability
Pitfalls of Working in Family Medicine Presented by:
Pitfalls of Working in Family Medicine Presented by: www.thehealthlawfirm.com Main Office: 1101 Douglas Avenue Altamonte Springs, Florida 32714 Phone: (407) 331-6620 Fax: (407) 331-3030 Website: www.thehealthlawfirm.com