Identify the steps in the medical documentation process.
On our prior discussion 2.1 we explained step by step the medical documentation process here is the resume brake down and we must follow to avoid delays on payments.
Patient check-in Insurance eligibility and verification Coding of diagnosis, procedures and modifiers Charge entry Claims submission Payment posting Explain why medical documentation is required.
We must complete a proper and accurate documentation this way the communication is efficient between provider to provider and members also insurance company regarding patient preventative care, health status and delivery of care.
List the principles of documentation.
The medical
When educating our patients it is important to make sure that all education is documented. Documentation of all patient education is important because this will provide legal record for the nurse. It is also important in documentation that this will validate that all standards of care are being met. The Joint Commission will review charts and audit for the proper documentation such as patient education. The result of proper charting will provide reimbursement for the hospital, along with creating a safe environment for the patients. When it comes to the Joint Commission it also brings importance to tactics for patients with low literacy. As part of making care patient-centered, healthy literacy comes into play. When documenting this is an area that nurses have accountability for in order to create a safe learning environment. There is a high rate of medical errors and adverse events related to communication breakdowns, now widely recognized, are also widely acknowledged to be untenable (Edwards). The Joint Commission allows for guidelines to establish patient-centered care in order to create the best outcomes for
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
The process of clinical documentation improvement has a defined list of goals it needs to meet. They are to have accurate Present on Admission documentation, reviews of records going to all payers, accurate public reporting of diseases and illnesses, specific and accurate codes, decrease the volume of third party denials of claims, and reduce risks through recovery audits. CDI professionals also need to be able to work well with people in many different roles as they will work with a variety of departments during their work of ensuring an accurate written
The foundation to being a good coder is having a thorough knowledge of medical terminology. When we communicate with other people in the healthcare field, the universal language used is medical terminology. When we abstract information from the doctor's notes to code, they will be using medical terms. If we do not have an understanding of the terminology, we could code for the wrong thing and have the claim denied.
The health care provider should ensure that they communicate effectively with the patient/client.
The government decides the level of fees. Fees are charged for treatment at the health centres and hospital outpatient care. However, there are no fees for inpatient treatment.
Medical Billing and Coding is very important to medical professionals, I am choosing this career because I know it will always be needed and I can learn something new everyday. In the Medical Billing and Coding field I can work at various locations. I can work at a doctors office doing Office Administration for the providers. For example, I have previously worked in a counseling office for social workers, counselors, and psychologist. I did the billing two days a week and learned many traits that will help me better my career. In an office setting, there are many different provider types so depending on the office that I work for I will be able to learn various types of billing. I also can work in a hospital doing institutional billing for the facility.
A Clinical Documentation Specialist is the person that makes sure all the records are accurate and updates the documentation as needed to maintain the required level of accuracy in the medical records. A CDS resolves documentation issues as they arise, and must have a solid working knowledge of multiple forms of medical coding, and is the professional that follow-ups with physicians and informs medical staff members of updated documentation methods. A CDSS has a wide base of knowledge, as indicated by the CDS certification website www.hcpro.com; “Clinical documentation specialists possess knowledge of a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
I feel that when dealing with patient communication confidentiality is the most important matter at hand. The patient has entrusted the doctor’s office to handle there help care with the utmost of care, professionalism and to keep their matters private. If a patient confidentiality was broken the entire office would be effected. Patients would no longer trust the doctor and his staff. When sending out any information you must always double check the patient name, email address/physical address, and fax number to make sure the information is being sent to the correct person.
My chosen career field is the medical field( EKG Technician). The importance of knowing the medical terminology in this particular is something that you need too know and you must study hard. Working in a doctors office or a hospital and speaking with other physicians or assistants you should know these terms and what they are talking about. If you are not sure of what is being said then it is always good to ask someone who knows what they are talking about so that you may get a better understanding of what's going on. Knowing what the physicians are talking about can help you in the long run. It can also help you in your everyday life and work. Learning these medical terms will help you to carry on a conversation and not look baffled when
It can be very challenging for health care organizations to choose a Health Information System (HIS) that best fit their needs and adequately assist their workflow and standards which can result in lowered clinical mistakes and enhanced safe patient care. This paper will focus on the following features of HIS: the electronic medical records (EMRs), clinical decision support systems (CDSS), medication administration records (MARs), and the computerized provider order entry (CPOE). The EMR, also known as the electronic health records (EHRs), are data processing machines that serves as a warehouse of patient information that can be retrieved by the clinicians, patients, insurance parties, drug companies, research registries, and the government.
Recommendation: A motion was made by Dr. Simon to approve the Physician Admission Order form with the proposed changes. The motion was seconded by Dr. Hines, and unanimously carried.
A prescription means documents which consist the medicine prescribed by a medical professional and are regulated by the government. The medical professionals can authorize prescription medicine including physicians, nurse practitioners, dentists, veterinarians, psychologists and optometrists[22]. They include the superscription or heading with the symbol "R" or "Rx", which stands for the word recipe (meaning, in Latin, to take); the inscription, which contains the names and quantities of the ingredients; the subscription or directions for compounding the drug; and the signature which is often preceded by the sign "s" standing for signa (Latin for mark), giving the directions to be marked on the container [23]. A prescription should contain:
A person needs to be able to document numerous amounts of information in a neat and organized manner in the most accurate way possible. A nurse in the field needs to be able to organize medical records and provide the information needed to help improve the quality of health care to the patients. For providing the health care personnel with accurate information is important to delivering quality care to the patients and improve job performance of other nurses, doctors and other medical staff and