Medical Records

In: Business and Management

Submitted By bigpete2012
Words 361
Pages 2
Peter Blackwell
Chapter 2 Test
April 30, 2012

(1) Distinguished between the care provided in a/an:
a. Hospital treats the acutely ill whereas a SNF cares for those less acutely ill. b. Level of care required is less in ICF c. RCF residents carry out activities of daily living on their own, whereas ICF residents may need some help. d. Trauma center is equipped to handle more severe injuries.

(2) Distinguished between:
a. Medicare id for people age 65 and older. Medicaid is for the poor.
b. Retrospective is upon or after discharge, concurrent is during hospitalization.
(3) Describe the type of care provided by a Primary Care Centers. Basic care by an internist, family practice physician, or pediatrician
(4) Name :
(a) An ancillary service . X-ray, labs test, physical therapy
(b) A primary care physician. Internist, family practice physician , or pediatrician
(c) Medical ,surgical, newborn, obstetrics
(d) AMA (against medical advice
(e) 14
(5) State the term for :
a. satellite
b. hospice care
c. swing beds
d. observation beds
e. respite care
f. intrahospital transfer
g. incident report
(6) Identify the initials AMA as related to discharge. Against Medical Advice
(7) Is the adolescent included in adult or children statistics ? Adult
(8) Name a list compiled daily in a hospital ? Admission, transfer, death, discharge
(9) Name three indexes maintained in a a hospital. MPI, number, disease, procedure/ operation
(10) name a register maintained in a hospital. Admission-discharge, birth and death
(11) Using the list in this chapter for assigning service classification classify the following diagnoses:
a. CV
b. Auto immune
c. endocrine
d. CV
e. GI
f. Pulmonary
g. NB
h. Urology
i. Neurology
j. ENT
k. GI
l. Psych
m. Ortho
n. Hem or Gyn
o. Oncology
p. NB or Peds
q. Neurology
r.…...

Similar Documents

Electronic Medical Records

...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......

Words: 2468 - Pages: 10

Electronic Medical Records

...Electronic Medical Records and Safety Paper Healthcare can be known for a complex industry. Every day is a new day facing complicated clinical administrative transactions with electronic medical records and safety? Health Information technology is suppose to realize errors using electronic medical records. Leaders must understand the complexity and safety issues in order to help mandate electronic medical records with design, development, implement and use. In the last decade, this article has informed executives, clinicians, and technology. Their main focus was on these three areas computerized physicians order entry. Their main focus was to work all three areas computer physician order entry, computer decision support system, and BCMA. By following these guild lines it will reduce the medical errors. Electronic medical records are set in place to reduce medical errors or produce a new safety risk that result in harm. A threat to patient safety can be seen during the planning design, development testing or while in operation and working on maintained the security of the records. Within each of these process, technology people and the work environment can individually or collectively generate errors(Ash, Berg, and Coiera 2004) Software driven products make it complicated technology which can rise health care cost and harm patients at the same time. Healthcare workers environment has excessive noise, high workload complex tasks. Active errors are......

Words: 833 - Pages: 4

Medical Records

...Medical record keeping has change in the last couple of decades. In the past patients records were kept in a file on paper taking up excessive room. In the past, paper charts were the only means of keeping a patient’s medical diagnoses documented. Some of these charts are still used today in healthcare facilities, lately; there have been great advancements in the medical field involving the creation and maintenance of patient records. There are electronic medical record computer systems and internet-enabled doctor correspondence methods. All of this is to make the experience better for the patient and easier for the medical provider. In 2009, the 111th Congress allocated $19 billion of the American Recovery and Reinvestment Act, toward the creation of an electronic health record (EHR) for each person in the United States by 2014. The recent debate over EHRs has focused largely on the economic, logistical, and political consequences of implementing such a system; however, the country should also contemplate the ethical ramifications of EHRs. Addressing these concerns requires the application of ethical principles such as autonomy, justice, beneficence/non-maleficence, and privacy and confidentiality. The use of electronic technology for the management of health information presents expanded security risks due to increased capacity and mass storage. A single breach in security could lead to the unauthorized disclosure of private health information. Both health care......

Words: 877 - Pages: 4

Impact of Electronic Medical Records

...Impact of Electronic Medical Records April 7, 2013  Technology has brought the world of medical services a long way throughout the years, including the introduction of electronic medical records (EMR). But does the use of the EMRs benefit patients or does it put patient confidentiality at risk? First, to understand the impact EMRs have on each and every one of us, understanding of EMRs is necessary. “An electronic medical record is a digital version of a paper chart that contains all of a patient’s medical history from one practice”. (U.S. Department of Health and Human Services , 2012) EMRs allow medical providers to access information quickly and accurately. There are many benefits to using EMRs over paper copies, such as allowing providers to track data over time, identify patients who are due for preventive visits and screenings, monitor how patients measure up to certain parameters, and most importantly improve overall quality of care in a practice. (U.S. Department of Health and Human Services , 2012) Paper copies of medical records require enormous amounts of storage space to maintain compared to EMRs. Providers are required that records be retained for a certain amount of time. “Providers should keep health information for at least the period specified by the state's statute of limitations or for a sufficient length of time for compliance with laws and regulations”. (Donna M. Fletcher, Gwen Hughes, & Harry Rhodes, 2011) Physicians tend to have poor......

Words: 1179 - Pages: 5

Electronic Medical Records

...Electronic Medical Records Technology is advancing every year. One way that technology is advancing in health care organizations is the use of electronic medical records. Electronic medical records (EMR) are a digital way of recording a patient’s medical history. EMR’s are a more convenient way to save a patient’s medical history rather than using paper based medical records. More physicians and hospitals are now using electronic medical records. “The availability and utility of electronic medical record (EMR) systems provide a new basis for competition among physician groups and hospitals as well as an opportunity for early adopters to get a competitive jump on their rivals” (Moseley, 2009, pg. 104). Patients want to see a physician that has up-to-date equipment. With the amount of competition in health care organizations, most physicians want to use up-to-date equipment, especially if they want to be a step ahead of their competition. There are many benefits when it comes to electronic medical records. One benefit is efficiency. Using computers for storing a patient’s medical history is more efficient than using paper charts that can get easily lost. Another benefit would be saving time. Physicians can get quick access to a patient’s medical records if they are filed electronically. Saving money will be another benefit. Hospitals and Primary Care Physicians will not have to provide space for filling medical records if they are filed electronically. They......

Words: 1429 - Pages: 6

Electronic Medical Record

...Electronic Medical Records Christina Pierre HCS/490 Monday August 26th, 2013 Dr. Alex Kadrie Electronic Medical Records The Electronic Medical Record (EMR) is a digital version of a persons’ medical record that contains the same information as paper record except it comes in an electronic form. The EMR is much more secure than paper record. The access of EMR is limited to staff who have a leg mated “need to know” for treatment, payment, or operation purposes. The EMR system is designed to prevent unauthorized users from gaining access to a patient medical record through safeguards. The system is intended to track patient’s entire health and medical history in an electronic format. A patient’s information can easily be retrievable and can make a patient navigate through the health care system much safer and more efficient. The Electronic Medical Record can help organize patient information better, such as diagnoses, medications, and test result in a way that make guidelines easier to follow. It can provide automated prompts and reminders for when tests are due or when control of chronic disease is suboptimal. Through a tracking system and disease registries the EMR can improve patient care from outside to identify potential quality problems. The EMR also support diseases registries and reports to identify the patients who need follow-up appointments. The EMR can......

Words: 1014 - Pages: 5

Medical Records

...Are Electronic Medical Records a Cure for Health Care? 1. Do to the current method of medical record keeping is one reason why health care costs in the United States are so high. The majority of medical record keeping here in the United States is paper it makes it difficult to access and share. 2. The factors responsible for the building of electronic medical record systems are like organization, doctors, insurance companies, patients, and the lacking of technology. Doctors difficulties is that they have limited time and to take 20 hours of training to use the EMR. The United States government also plays a big role by having a short term goal that by 2015 that all medical facilities will be utilizing EMR. And patients have a concern of confidential information that will be stored in this system that can be read all across the United States. 3. The business, political, and social impact of not digitizing medical records are that doctors will not be able to have instant access to a patient’s medical records. And without digitizing medical records means that there will be the need for more paper work. Politically the 2015 goal set by the US government would also be impacted. Socially people would expect little error to this EMR system like correct dosages. And by not digitizing medical records has a greater risk of errors. 4. The business and social benefits of digitizing medical recordkeeping are when taken from paper and filing them to the EMR......

Words: 1289 - Pages: 6

Electronic Medical Records

...Electronic Medical Records Jacynthia Mcgill-Rice HCS/440 July 13, 2013 University of Phoenix Pamela Cromity, Instructor Abstract Emergency systems improve the quality of care, save money, and improve efficiency using familiar research technology for the health care industry. Larry Weed an amazing visionary physician who in the 1960’s, stated that health care providers should be able to document findings, and research patients information quickly and easily in their electronic medical records. The concept of implementing electronic medical record is also to allow third parties to independently verify diagnosis accurately in a timely manner. The EMR system provides effective communications among health care professionals and providers, such as radiology, laboratory, and connection with patients who experience chronic pathologies under the care of multiple subspecialty care providers. In this paper will speak about advantages, disadvantages, and the challenges within the communication of electronic medical records. Electronic Medical Records Electronic medical records have been around since the 1960’s. As medical care becomes more complex new data is already overwhelming health care professional’s capacity to treat patients with the latest information...

Words: 1116 - Pages: 5

Electronic Medical Records

...Electronic Medical Records Jordan Smith HCA/210 June 16, 2013 Electronic Medical Records Electronic Medical Records or EMR have begun to be more and more effective in the care and treatment of patients. The communication between patients, doctors, and other staff members is better than ever before. The amount of well received care and treatments has increased greatly with the advanced use of Electronic Medical Records usage (PR Newswire, 2013). The delivery of health care to patients has been greatly improved by the use of EMR, due to the fact that patients do not have to spend so much time repeating past medical history to every physician, nurse, or other health care professional they come in contact with. Health care has also been improved by EMR by being able to offer a continuity of care to those who have chronic diseases, through better management and coordination (PR Newswire, 2013). By using this kind of medical technology, providers, insurance companies, and patients allows providers to gain access to patients medical records quicker, send prescriptions to pharmacies, and work alongside other physicians to ensure the patient receives the best care possible. I believe this author has a good sense of what EMR can really do for the patient and provider. Knowing that health care can be made easier by using Electronic Medical Records makes this author’s case relevant. I do think the author could have dug a little deeper into the topic of EMR, but it did show how...

Words: 329 - Pages: 2

Electronic Medical Record

...There are many ways that electronic medical records can be beneficial to the nation. It can lower the cost of health care, profiting the healthcare industry as a whole. We desperately need lower cost in this economy, if health care cost decreases then it might be affordable to everyone. Then no parent would have to decide whether or not to pay the medical bills or buy food. Electronic medical record keeping will also improve the quality of care, medical errors might substantial decrease and the health care prove would not have to depend on a patients memory. With being in the military my family and I are always moving, changing provides and medical facilities constantly. I as a patient can't remember all my history plus my children, so the electronic medical record would be a great help for myself and my provider. I remember a friend of mine got into a really bad accident on an out of state trip, they couldn't figure out what was wrong with him, he fell into a coma. Come to find out the medicine they gave him interacted with medicine he was already taking. There was no way the doctors could have known, if this technology was around it would of saved him and his family a lot of heart and pain. His records would have been easily obtainable even far away from home, ensuring a better standard of care for him. Patients might also benefit because it would be harder for mistakes to be made because of hard to read records. Some problems that this might encounter is that it might...

Words: 312 - Pages: 2

Electronic Medical Records

...Electronic health records are becoming more common as a means of recording patient information. In some cases, the transition from paper charting to the use of electronic medical records has not been easy. Nurses may find the system more time-consuming and more difficult to use initially. Without modern technologies decision support systems cannot be effectively integrated into routine clinical workflow. Electronic health records present many advantages over writing medical records. As with any new system, electronic health records will take some time in adjusting. As the use of electronic health records becomes more common, nurses will undoubtedly adjust as they become more familiar. “Acquiring immediate access to key information such as patients' diagnoses, allergies, lab test results, and medications is readily available. It has improved caregivers' ability to make sound clinical decisions in a timely manner. The ability for providers participating in the care of a patient in multiple settings quickly access new and past test results would increase patient safety and the effectiveness of care” (New England Journal of Medicine 348, no. 26, 2003: 2635–2645). “The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed to execute orders. Using reminders prompts, and alerts, computerized decision-support systems would help improve compliance with......

Words: 1339 - Pages: 6

Electronic Medical Records

...Computer Based Medical Records Abstract In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system. Computer Based Medical Records Electronic health records are taking over the paper medical records in doctors’ offices and hospitals everywhere. Electronic health records will help physicians with the continuity of care of their patients. The communication between different doctors and hospitals and also within the office is much faster and easier. Coordinating the electronic health record is much easier. The system is laid out in ways that makes it easy to use and document and also find information when needed. Finally, the accountability of the system is excellent. The electronic health record will help physician’s continue care with their patient’s in a lot of different ways. The electronic systems allows for easy access and sharing of patients health records. (Chheda, 2005) A......

Words: 1213 - Pages: 5

Electronic Medical Records

...The electronic Medical Records system can be a blessing and a curse for the Medical Facility. It can be a blessing when it is done correctly because the patient information is there on hand along with appointments, medications, ultimately the entire medical history of the patient, right there for the provider to see at a glance. It also helps the patient; that they no longer have to give their medical history over and over again with every new provider they see. Also, the record of immunizations for the children is there online, and can be accessed at any time by anyone with those privileges, enabling the parent to breathe normally, no longer worrying whether or not you’ve lost the hard copy of the shot records and your poor little one will have to get all those shots again or not. Electronic medical records can be a curse when not done correctly. I work for the Department of the Army, and they are still in the process of fully implementing Electronic Medical records, and it is indeed a blessing and a curse. When you have a contractor/system in place that does not allow for swift corrections of errors to records, merging of duplicate records, etc. it can be hard on the patient because they sometimes have problems getting care because their electronic medical records are all messed up. Also, it takes anywhere from 4 weeks to 4 months to get a record cleared up and corrected because the system is universal and it there are literally millions of entries to be......

Words: 271 - Pages: 2

Medical Records

...Electronic Medical Records Megan Granger HCS/320 March 4, 2012 Lynn Belle What is Electronic Medical Records With the technology created, paper-based medical records have entered the state of existence. According to “Electronic Medical Records” (2005), “A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems)." For over decades studies have been trying to create something for provider and patients to improve the communication between the two. Slowly each and every medical facility is switching from paper to electronic medical records, weighing out the inns and the odds (Electronic Medical Records, 2005). Impacting Communication in Healthcare Being one of the goals for creating and enforcing electronic medical records, communication has seen better outcomes. The electronic medical records systems contain availability to all notes, reports, lab work, and scanned documents. When a patient is communicating with the provider, all information what is said,......

Words: 1208 - Pages: 5

Electronic Medical Record Speech

...A electronic medical record is a paperless, digital and computerized system of maintaining patient data. Electronic medical records are designed to increase the efficiency and reduce documentation errors by streamlining the process. Electronic medical records have allowed various doctors from around the world to treat patients, offer advice, consult and perform surgeries together because of the utilization of electronic medical records. No longer are the test results interfering or blocking a patient from receiving the necessary medicine, treatment or procedures that they need to become healthier. Implementing electronic medical records is a complicated and complex process as well as a expensive investment. Efficiency isn't the only benefit of electronic medical records. Access to patient care becomes easier and safer when records are shared. The sharing consists of blood type, prescribed medication and medical history. Convenient access to electronic medical records can be life saving in the event of a emergency. The major features of electronic medical records are: -patient history (this is information that will be needed to identify the patient; address, date of birth, social security number as well as their entire history concerning their visits to your facility) -clinical charting (clinical charting will help to easily access and pull up the patients information this will alleviate any lingering hours of searching for a patients chart) -lab orders and results(are......

Words: 704 - Pages: 3

Peppermint FRENCH DVDRIP 2018 | Chuukan Kanriroku Tonegawa - Episode 23 | IAHCSMM Workbook Chapters 17-20