Medical Health

In: Other Topics

Submitted By tiffany922
Words 1299
Pages 6
Associate Level Material
Medical Report

This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.

The following suggestions will help you get started:

• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.

• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.

• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.

• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.

• For the Diagnostic/Lab Results, include the testing or procedures required to prove…...

Similar Documents

Modern Medical Practices vs. Alternative Health Practices

...Modern medical practices vs. Alternative health practices Robin Phillips English composition 1 Sarah MacDonald July 16, 2012 Modern medical practices vs. Alternative health practices With the countless illnesses of today, there are various options available in the health field to receive the care and treatment desired. Two of these choices are with the General practitioner and a Complementary & Alternative health practice. Comparably, both practices treat the same set of common illness’s or diseases such as pregnancy, childhood illnesses, common cold, asthma, diabetes, high blood pressure, depression, injury, and anxiety; however, there are differences in the technique to treatments and healing methods, which should be considered in choosing the type of practice that best fits your needs. In order to discuss the similarities and differences between the two practices we must first define them. A general practitioner, that practices modern medicine is defined by Collins English Dictionary as “ a physician who does not specialize but has a medical practice (general practice) in which he deals with all illnesses” (2005); while defines Complementary health as” also called: alternative medicine , the treatment, alleviation, or prevention of disease by such techniques as osteopathy, homeopathy, aromatherapy, and acupuncture, allied with attention to such factors as diet and emotional stability,......

Words: 1287 - Pages: 6


...Medical Assistant: Medical assistant possess good critical thinking skills and are able to pay attention to details. Empathy, flexibility, self-control, integrity, willingness to learn is other important traits of a medical assistant. Additionally they must have a neat professional appearance, good communication skills. Most medical assistants have both clinical and clerical responsibilities. Clinical functions vary depending on the scope of duties permitted by the Laws of each state. Their responsibilities may include helping the physician by obtaining the patient’s medical history; taking and recording the patient’s height and weight; obtaining and recording vital signs, such as pulse, temperature, respiration, and blood pressure; preparing the patient for examination and/or treatment; drawing blood; assisting in examining And/or treating the patient; performing routine laboratory tests and EKGs; Applying dressings; instructing the patient in preparation for x-rays and laboratory examinations; preparing and administering medications as directed by a physician. The clerical, or administrative, responsibilities that a medical assistant may be expected to perform include scheduling and receiving patients; transcribing and maintaining medical records; procedural and diagnostic coding; typing and taking dictation; arranging for hospital admissions and laboratory procedures for patients; and handling telephone calls, correspondence, reports, insurance matters,......

Words: 1305 - Pages: 6

New Health Medical Systems

...New Health Medical Systems Shari Gifford HRM/548 Jennifer Familant March 10, 2014 New Health Medical Systems TO: New Health Medical Systems, Board of Directors FROM: Shari Gifford, HR Consultant CC: Jennifer Familant DATE: March 10, 2014 SUBJECT: Staffing Strategy It is my understanding that you, the Board of Directors of New Health Medical Systems, recently announced a new strategic direction to become a regional center for critically ill patients. As a part of that strategy, New Health Medical Systems (NHMS) has opened a new cardiovascular unit where patients can receive care for heart attacks, strokes, and other types of cardiovascular diseases. NHMS was quickly able to recruit a quality physician to head the unit as well as additional professional staff, however finding qualified technicians have become much more difficult than originally anticipated. The problem does not seem to be so much in terms of the position being attractive to candidates, but rather a lack of skilled technicians in the immediate region. Most of the skilled technicians are already employed, and are not actively seeking jobs with other organizations. In order to fill the 35 technician positions, the director of staffing has created a new staffing strategy that includes the following: 1. Place advertisement in the local newspapers 2. Contact staffing agencies that specializes in placing technicians into health care facilities 3. Organize a job fair and invite local...

Words: 630 - Pages: 3

New Health Medical Systems Staffing Strategy

...New Health Medical Systems Staffing Strategy HRM/548 Gwendolyn Ford June 2, 2014 Jennifer Familant One of the main issues that needled American today is the provision of a new strategic healthcare system. With Medicare on the rise the prediction is by the year 2019 there will a vast number of people uninsured and depending on Medicare to compensate for medical treatment. The primary issue of healthcare in the United States is a leading part of the health medical system staffing problem because the staffing relies on Americans utilizing physician care. Understanding and developing current strategies will align organizations with new innovative ways to implement business strategic direction, and recommend staffing strategies that will meet the need of the organization’s goals are topics that will be address in this paper. Communicating a guided vision is the key role to planning strategically. Implementing any type of plan for the business should be deliberate strategically in order for the business to operate daily. The involvement of a diverse team of employees at any level in the organization can help to construct a communal vision, and growth all individual's in the organization motivates to understand the success of the plan. Simplicity and constant communication, from planning anticipate consequences that design the measure of performance can be vital to the success. Effective staffing frequently involves groups with simplicity of the shared vision, and extensive...

Words: 709 - Pages: 3

Are Electronic Medical Records a Cure for Health Care?

...Are Electronic Medical Records a Cure for Health Care? Abstract In the United States, healthcare remains a top priority and is consistently part of the national public policy agenda. Political leaders and healthcare providers attempt to address issues of quality, access, efficiency and affordability. Solutions to these challenges are being pursued through a great variety of strategies and methodologies ranging from adoption of best practices of patient care to negotiated contracts between payers and Care Delivery Organizations (CDO.) (Gonzalez, 2014) This writing assignment will take a look at the adoption of Electronic Medical records and show the strengths and weaknesses of overhauling medical records from paper to digital. Context The purpose of writing this paper is to give me a better understanding on how information systems can help the medical field. However, it is important to understand that you cannot just overhaul the current system in place. There needs to be a process involved to get everyone at stake the proper training and information needed to undergo such a large transition. Introduction Electronic Medical Records are basically electronic versions of paper-based medical records. An Electronic Medical Record (EMR) is essentially an electronic record of health related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff in one healthcare organization. Electronic medical record......

Words: 1353 - Pages: 6

Managing Medical Ethics and Legal Requirements in a Primary Care and Health Environment

...Level 5 Diploma in Primary Care and Health Management 4419-601 Managing Medical Ethics and Legal Requirements in a Primary Care and Health Environment TABLE OF CONTENTS TASK | PAGE | Task 1Managing medical ethics is a fundamental part of a Manager’s role. It is the responsibility of the Manager to understand the guiding principles of medical ethics and apply them within the organisation | | a) Reflect on the journey of medical ethics and interpret how the principles of the Hippocratic Oath are applied within your organisation………………………………….………… | 4 | b) Examine your workplace with reference to its compliance with the legal and ethical requirements of holding, using and accessing data………………………………………….………. | 6 | c) Evaluate your role as a manager in ensuring compliance with the principles of medico-legal ethics in relation to duty of care ………………………………………………………… | 8 | d) Regulatory bodies are used as a means of support in the event of fraud and malpractice. Analyse the route or course of action you would follow if you were to identify evidence of potential fraud or malpractice within your organisation…………… | 9 | Task 2There are a variety of medico-legal requirements affecting healthcare organisations and the Manager is required to understand how these requirements impact not only on the medical profession but on the organisation as a whole. | | a) Review relevant medico-legal requirements relating to consent and capacity,......

Words: 4907 - Pages: 20

Medical a major factor in an office setting, weather it is in the health care industry or any other office setting. Before a health care worker performs any medical procedure or care task with a patient, it's important they use verbal communication to inform the patient. This allows the patient to know what to expect. Verbal communication can also be used by the patient to inform the health care worker how they are feeling, what concerns they have and any other questions the patient may have. Non-verbal communication in the health care setting comes from eyes, hands and other parts of the body. Providing eye contact, not crossing the arms and leaning in when talking to a patient are non-verbal ways to communicate you care. Non-verbal communication is usually understood as the process of sending and receiving wordless message. Types of non-verbal communication are touching and eye contact as well as body language. Touches can be defined in communication as a handshake or a high five or a shoulder pat. Eye contact and facial expression helps indicate important social and emotional information. Body language is particularly important in group communication. It can convey attitudes, emotions, and feelings to someone who knows what to look for. Crossing your arms is a sign that your unconsciously shutting someone out. It’s similar to keeping someone at arm’s length and not allowing them to get closer to you. In the medical profession doctors can pick up on these signs. The care......

Words: 1359 - Pages: 6

Hrm Week 1 New Health Medical

...New Health Medical Systems Memo HRM 548 March 9, 2015 New Health Medical Systems Memo Memorandum To: New Health Medical Systems Management From: Human Resources Date: March 10, 2015 Re: Staffing Strategy A thorough review and evaluation has been taken over the new staffing strategy presented in regards to changes to the New Health Medical Systems Corporation. The company is seeking to strategize a plan that will take the company in a new strategic direction. Rivenbark, (2004) stated that the human resources employee’s role includes, acquisition, assessment, development and retention within the organization. (p. 1). Since recruitment has presented a challenge within the local area, we may need to consider a wider and very diverse demographic in order to fill those positions. There is the option of utilizing social media outlets and radio outlets. Social media and radio outlets have a farther marketing reach. In addition to the media outlets, one may need to consider the outlying areas where there may be talent that fits our criteria. Once the ad goes viral on social media and the media plays the ads on the air; this will open the door for employee referrals. One important thing to consider is that if the audience that the media reaches does not have a need for the position, he or she may know someone who does. If this is the case then we can pay employee referrals. The referral amount should be large enough to entice the referrals to apply, which will......

Words: 596 - Pages: 3

New Health Medical System Memo

...New Health Medical System Memo The director of staffing for a New Health Medical Systems has been required to create a new staffing strategy that will fill the 35 new positions opening up in the cardiovascular unit. She has recommended four strategies to help accomplish this goal: advertisement in local newspapers, staffing agencies, job fair for local professionals, and a signing bonus for contracts signed to complete 180 days. Below is a researched evaluation of the staffing strategies, including changes, or additional recommendations to the management. INTEROFFICE MEMORANDUM TO: NEW HEALTH MEDICAL SYSTEMS MANAGEMENT FROM: After careful review, the staffing strategy presented does not fully align with the company's new strategic direction. Staffing is the process of acquiring, deploying, and retaining a workforce of sufficient quantity and quality to create positive impacts on the organization’s effectiveness (Henenman & Judge, 2009). In this case, the staffing strategy cannot be solely based on hiring local candidates, but on creating incentives and branching out to candidates in other areas. Based on the needs of the organization, the following four recommendations were given for evaluation: 1. Place advertisements in the local newspapers. 2. Contact staffing agencies that specialize in place technicians into health care facilities. 3. Organize a job fair and invite local professionals to attend. 4. Offer a $1,000 signing bonus to anyone who joins......

Words: 616 - Pages: 3


...Maria Hernandez Mod 170 Ms. Lily Anesthesiology An anesthesiologist is a medical doctor who cares for a patient before, during and immediately following a surgical or medical procedure by administering the appropriate anesthesia and monitoring the patient for reactions and complications, and to ensure comfort and manage pain. Some of the primary responsibilities of an anesthesiologist include examining the patient to determine the type of anesthetic needed, communicating all relevant information to the appropriate medical practitioners, and administering local, intravenous, or spinal anesthetic to the patient. Anesthesiologists meet with the patient prior to the surgical procedure to evaluate their condition and to review their medical history, they will explain the procedure to the patient so that they know what to expect. During surgery, an anesthesiologist carefully monitors the patient's vital signs—including heart rate and rhythm, blood pressure, breathing, and kidney function—and adjusts anesthetics as needed. When surgery is finished, the recovery phase begins. The anesthesiologist administers medications to reverse the effects of the anesthetic, returning the patient to consciousness if a general anesthetic has been used. After surgery, patients are moved to a recovery room, where the anesthesiologist is still responsible for the patient's vital functions. In the recovery room, nurses and other specially trained staff closely monitor the patient under the......

Words: 1328 - Pages: 6


... Mary Jackson | 5656 Oak Street Detroit, MI 85533 Home: 123-456-7899 Cell: 123-456-7890 Email: | Objective | To obtain a position as a medical assistant in a medical facility where I can continue to develop and enhance my hands-on skills and knowledge in the medical field. | Qualifications | Certified Medical Assistant with medical practice experience.Proficient in performing administrative tasks.Extremely knowledgeable with clinical procedures.Clinical experience includes geriatric and pediatrics, as well as emergency triage capabilities.Excellent oral and written communication, able to effectively present information in one-on-one and small group situations to clients and other employees of the organization.CPR certified (valid until 2012). | Education | Detroit College of Medical AssistingDetroit, MI Associate Degree in Medical Assisting (2004) NHA Certification: EKG Technician, Patient Care Technician | Word Experience | Medical Assistant Dec. 2004 – PresentDetroit Family Health Center, Detroit, MIResponsibilities include obtaining vital signs on patients, performing venipuncture, preparing rooms and patients for examinations by physician, assisting physician during GYN procedures, performing pregnancy tests, preparing specimens to be sent for laboratory testing, and scheduling patients for office appointments and out-patient procedures.Perform other duties as needed including verifying patient insurance eligibility and authorizations, filling......

Words: 317 - Pages: 2

That Medical Error Affects Health Care Delivery

...Week Four Discussion Question A    A)    What are ways that medical error affects health care delivery? How can principles of quality be used to identify, correct, and prevent errors?  Medical errors can adversely affect a medical facility. A large number of publicly reported errors can result in a negative reputation for the organization. Medical errors are costly. It costs a large amount of money to settle disputes of medical errors. It can also affect the moral of the organization. Those involved in the error feel unable to function with confidence and staff will not trust the policy and procedures of the organization. Quality improvements are a never ending evolution. It is important that a health care organization not get comfortable in their quality policy and procedures. In order to decrease errors it is important to identify the errors that are occurring. These errors can be great or small. Reporting all errors in comfortable procedural manner will only improve the quality of care in an organization. If errors are not reported or downplayed there will not be the true reflection of what is going on, thus improvements will not occur. The staff must feel safe about reporting errors and understand that there will not be negative punishments for their report, but rewards for letting management know. Quality improves when they are all called to the attention of administrative staff. Ways to identify errors is to know the patients, know the staff,...

Words: 697 - Pages: 3


...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of......

Words: 12974 - Pages: 52

New Health Medical System

...| New Health Medical Systems | Memo To: NHMS Management From: Shakeia Cork CC: Date: 12/12/2011 Re: Staffing Strategy New Health Medical Systems is a large hospital and healthcare system in the southwestern part of the United States. The Board of Directors recently announced a new strategic direction to become a regional center for critically ill patients. As a part of that strategy, the organization has opened a new cardiovascular unit, where patients can receive care for heart attacks, strokes and other types of cardiovascular disease. It was quite easy for the unit to recruit quality physicians but there is a problem finding qualified technicians. The technicians in the immediate region are already employed and aren’t actively seeking jobs with other organizations. The director of staffing for the organization has been asked to create a new staffing strategy to fill the 35 new positions in this department. After considering alternatives, she is recommending the following. 1. Place advertisements in the local newspapers. 2. Contact staffing agencies that specialize in placing technicians into health care facilities. 3. Organize a job fair and invite local professionals to attend. 4. Offer a $1,000 signing bonus to anyone who joins the organization and stays for at least 180 days. After I evaluated the current staffing strategy, I don’t believe the adequate enough to fill the 35 new positions that are being offered. The strategy is still only focusing......

Words: 425 - Pages: 2

Veteran Affairs Compared to for-Profit Medical Health

...Veteran Affairs Compared to for-Profit Medical health care and Organizations Veteran Affairs versus For-Profit Medical health care and Organizations In assessing you will in regards to not for profit versus for-profit healthcare and companies I found an interesting article from the Congressional Budget Office [CBO] (2006), which smashes down the possession types of medical centers nationwide. Depending on 4,518 group medical centers, 58 % are Veteran Affairs, 18 % are for revenue, and the staying 24 % are government owned medical centers. Veteran Affairs medical centers were established for Veteran Affairs requirements and tend to be larger, and are more likely to be training medical centers. They also are responsible and responsible to the areas they offer. They are controlled by commanders of the areas they offer. Earnings obtained from the Veteran Affairs medical centers are reinvested to improve quality and health care provided at the medical centers, and also spent in group programs, such as offering no fee or reduced fees to the without insurance and low income for medical health care services. Veteran Affairs healthcare companies objective is to offer areas by offering healthcare without respect for a individual's ability to pay. For-profit medical centers are lawfully responsible to their entrepreneurs and stockholders and performance is centered...

Words: 303 - Pages: 2

Helios 58 mm f2 44-M-4 Lens | Kampf der Menschenaffen | 159 مسلسلات عربية مسلسل سايكو الحلقة 3 الثالثة مشاهدة مسلسل سايكو الحلقة 3 الثالثة تحميل مسلسل سايكو الحلقة 3 الثالثة