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Medical terminology the language of health care 2nd edition
Fundamental of medical terminology
Medical Terminology
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Assignment 1
In a Word document, prepare a 1-2 page (300-500 words) essay style to answer the following question:
Question:
Many hospitals adopt a major terminology system such as ICD, yet there is a need for specialized classification system terminologies, why do you think we need specialized classification terminologies? Describe at least 2 examples for specialized classification system terminologies?
Due Date: 7th February 2016
What is the medical coding:
Medical coding is to transform Description diagnostic of a pathological condition and health problems of surgical and medical procedures into digital and literal symbols and through the review and analysis of the medical record of the patient by specialists in health information management
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What is the role of medical encoder?
It converts descriptions and medical terminology for the diagnosis of injuries and medical procedures associated with medical symbols according to what is stated in the patient's medical file.
What are the medical coding method?
The Medical encoded full medical file of the patient review in addition to the review of electronic medical records in order to rid the relevant clinical, medical, process information, then be selected medical symbol for the correct diagnosis or other medical procedures in accordance with the International Classification of Diseases ICD-10-AM & ACHI and they enter that information in the database for later use in research and other uses.
Technical requirements of medical coding?
Good knowledge and familiarity with the knowledge of medical terminology and anatomy and physiology and pathology and pharmacology, and that access to accurate description of symptoms and diagnosis of patients. As well as surgical and diagnostic procedures and medical services provided to the patient dissuade receiving health care.
The benefits of medical
The American Health Information Management Association provides guidelines of elements to be included in a health care organization’s policies of a coding compliance plan. (“Coding Compliance: Practical Strategies for Success,” ahima.org, 1998).
Using standardized terminologies in nursing practice has a wide array of advantages to the patients, the organization involved, the nursing profession and even the country using the standards. These terminologies aid the healthcare organization (both the care team and administrators) in deciding which nursing terminology or a combination of several that suits their needs. With these terminologies:
Medical billers often communicate with physicians and other health care professionals to explain diagnoses or to attain further information by means of phones, email, fax, etc. The biller must know how to read a medical record and be familiar with CPT®, HCPCS Level II and ICD-9-CM codes.
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
medical practices are beneficial; they are done to cure people from illness and to save
Medical billing codes are used to communicate the diagnosis and treatment of a patient from the healthcare provider to the patient's payer (private insurance, Medicare or Medicaid). Those codes help the payer determine how much to pay the provider for services rendered to the patient. These codes allow for modifiers which describe procedures and services in greater detail. Modifier 22 When a procedure takes longer than it should, the medical coder can use Modifier 22 to indicate the extra work involved. Billers set a standard time interval for each procedure or patient visit.
Beneficence: a physician should be doing what is in the best interest of the patient
Medical Coding and Billing can help doctors by handling all the paperwork that has to be submitted to the insurance companies. They can also help by sending medical bills out to all the patients that have been seen by the doctor.
... basic information of the patient. Professional and precise language should be used when documenting. For the care plan, I have learned to correctly write a nursing diagnosis and writing interventions that are within nurses’ capability and suits the patient’s personal status. From now on, I will remember to distinguish medical diagnosis from nursing diagnosis. For each diagnosis, I will write about the patient’s (potential) response to the health problem and state why this might be the concern.
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
Many people don’t know the appropriate analytical skills to be able to recognize key details in patient's records and codes. Medical coders must be very detail oriented and accurate when it comes to this profession. “Coders translate medical terminology into a standard format allowing
Medical coding nomenclatures and classifications have extreme importance when assessing the patients’ diagnosis, billing, and more. They also make it possible to standardize health information so there is interoperability, accurate health information exchange, and reliable secondary data usage. The common medical coding nomenclatures and classifications are SNOMED CT, ICD-10-CM and ICD-10-PCS, and CPT. The implementation of these have changed medical coding and impacted the workforce in many ways. Outpatient and inpatient healthcare settings had to adapt to the systems’ requirements necessary to meet clinical and billing objectives.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
Question: 4.1- Discuss and appraise your approach to managing wounds that are classified as either healable, non-healable or maintenance. Comment on the differences of care approaches between these classifications.