Patient Check-in: This is the 1st step of the appointment and where the flow begins. The patient arrives to the doctor’s office and signs in on the “check in” clip board, most doctor’s office has one in the front desk. Usually it will ask for some basic information so the person on the desk can verify all information in the system is correct.
2- Insurance Eligibility and verification: Once you sign in on the clipboard and all information is inputted in the system correctly. The doctor’s office receptionist will verify that your current insurance covers the visit or verify your specific benefits. Usually this needs to be done prior to the appointment.
3- Coding diagnosis, procedures, modifiers: Once the patient has seen the doctor the
Identifying patients correctly when providing Care: Nurses are supposed to have two resident Identifiers when trying to care for a patient for the first time and after that, one identifier is acceptable. Identifiers such as Room number or location are not acceptable. To ensure this is carried out correctly nurses must ask for two identifiers in situations such as specimen collection, when providing treatments or when collecting blood for clinical testing (containers must be labeled in front of the patient). The Purpose of this guideline is to ensure that the patients are been properly identified and that they are receiving the right treatments and medications (The Joint Commission, 2012).
Van Doormaal, J. E., Mol, P. G., Zaal, R. J., Van Den Bemt, P. M., Kosterink, J. G., Vermeulen, K. M., & Haaijer-Ruskamp, F. M. (2010). Computerized physician order entry (CPOE) system: expectations and experiences of users. Journal of Evaluation in Clinical Practice, 16(4), 738–743. doi:10.1111/j.1365-2753.2009.01187.x
This paper will show how assessment is a core part of the client’s treatment. It will show how assessment is done at the beginning of the treatment process but, will allow you to see that assessment is a continuing process. It results from a combination of focused interviews, testing, and record reviews. Assessments give the social worker a framework of reference to understand the strengths, weaknesses, problems, and needs of the client for the development of the treatment plan. It provides the social worker with a theory-based framework for generating hypotheses about the client’s experience and behaviors, which in turn helps prepare the basis for a specific treatment intervention. This paper will discuss the assessment tools
The article “Promoting the 6Cs of Nursing in Patient Assessment” by Clarke (2014), is one that covers the different elements of patient assessment, how critical thinking is required in assessment and how nurses can integrate caring into their nursing process, primarily during patient assessment. Patient assessment is the first part of the nursing process and requires the nurse to collect objective and subject information for analysis that can be then attributed to a nursing diagnosis (Potter et al., 2014). Even after a diagnosis has been made, nurses must continue to assess and analyze their patients in order to ensure the patient is in good condition and that treatment is going as planned (Potter et al., 2014). In the case of critical thinking, it is “a complex phenomenon that can be defined as a process and as a set of skills” and often focuses on sound logic and reasoning (Potter et al., 2014, p. 141). The definition of Caring differs somewhat depending on the theorist, but in essence it boils down to a concept central to nursing that requires the nurse to support the patient in their health,
Michelle Knuckles, RHIA is the manager of Inpatient Clinical Documentation Improvement and Coding at the University of Utah Hospital. Clinical Documentation Improvement is the vital process of ensuring that records are complete and accurate. There are many types of problems that can occur in patient records, such as conflicting information, inconsistent diagnoses, vague documentation, or illegible information. The accuracy of severity of illness and risk of mortality are also important factors for a CDI professional and the organization itself. If a record has inaccurate MS-DRGs, CCs, MCCs, APR-DRGs, or mortality index; the hospital is unable to truly participate in hospital compare through Medicare and cannot create an accurate picture of their stance compared to state and national benchmarks. The role of a CDI professional is to catch these problems and assist in resolving them which results in a complete and accurate record at the time of the patient’s discharge. CDI is an important part of a patient’s quality of
I recall an event where I was asked to volunteer to attend a patient who only spoke Nepali and refused to talk to anyone in the hospital. As I arrive into the room and I start to greet her gently in Nepali by saying “Namaste”, the patient smiles and feels that she can trust me. As I stand beside her, she explains to me why she chose to not call anyone in the event of emergency. Additionally, she explains that’s she cannot trust any of the doctors because she can’t really understand what message they are trying to convey. She feels ashamed that her daughter might judge her for being an alcoholic. I listen silently and I ask her a few medical questions under the supervision of Dr. A. Zuckerberg at the University of Colorado Hospital. I sit down
This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has learning disabilities it was imperative to identify any barriers with communication (Nursing standards 2006).
When the students pay any money for the walk-in clinic or doctor, they have to obtain receipt of the payment; the admission office will assist to claim their money back.
Because there are so many different places to cover, the hospital takes extra precautions to make sure everyone is protected. They installed physical protection such as time delay lock and alarm system, panic alarms, cameras, photo I.D. system, and IT security. Once you are a hospital employee, you give the security department the license plate on your car. You then make a badge that allows you to get into different doors that are locked for the protection of others. Also you set up different passwords that allow you into the computer system. Once you set up your passwords for the computer you are then allowed to get into every patient 's chart, however you shouldn’t do that unless you are assigned to that patient. There are certain rules that exclude you from going into other peoples chart, it is called HIPPA. HIPPA protects all of your medical information that only you are allowed to say who can know about your medical information. However if you are in a hospital setting there is a system that shows who is in your chart. If it is not a hospital personal that is assigned to you, they will get fined and may get prison time. Other than having an IT system the hospital security can patrol the hospital without even leaving the security
The individual I had the pleasure of interviewing was a German/Mexican 86 year old female patient who was admitted in because of a fall at home resulting in a hip fracture. She is a petite woman with a full set of thin, white hair and she does not wear make-up. She was comfortably dressed in a dark blue/gray stripped t-shirt and a pair of black pajama pants with yellow slip-resistant hospital socks. Although she had some hearing difficulties, she was fully alert and oriented. The room where she was staying was plain. Other than her hygiene products, extra clothes, and purse, she did not have many personal items that personalized the room. She is temporarily staying in the acute facility, meanwhile she receives physical therapy.
Because I find Jane to be one patient and not two separate individuals, it is my stance that she is the one that the principle of respect for autonomy applies. That is, as the fetus’s host, Jane should be the only one that is able to make choices in regard to the fetus.
Kye Poronsky the is a bright and warm person. As she welcomed me into her office she greeted me with a sincere smile and offered me some chocolate macaroons. During our initial small talk she was at ease asking the basic questions while really listening to the answers I gave. She seemed unguarded speaking to me as if I was an old friend. I asked her about the mission of the organization and the major activities that it took part in. Her answers were to the point and well phrased. I got the feeling that she has answered questions along these line many times before and has memorized the answers giving them as if they were second nature. It was not until I asked her if she felt the government asked too much of her department that she took a pause before carefully formulating her answer. The
Coleman, S. A. (2014). Protecting yourself against surgical smoke. OR Nurse 2014, 8(2), 40-46. Retrieved April 18, 2014, from http://journals.lww.com/ornursejournal/Fulltext/2014/03000/Protecting_yourself_against_surgical_smoke.9.aspx
The wound that I observed at clinical was a diabetic ulcer. It was located on the patient’s left hallux. The main factors that placed the patient at risk for developing this ulcer was diabetes mellitus and having a history for smoking for 30 consecutive years. The patient stated that his history of diabetes and smoking has led to him having poor circulation in his legs and feet. Another factor that could have influenced the development of his ulcer is immobility due to an amputation.
A master degree clinician should be deemed as a “clinical psychologist” for several reasons. The term clinician is often used to describe someone who provides mental health services, such as assessments, psychotherapy, evaluations, and diagnoses. Masters level clinicians and doctorate level clinicians provide services to people with psychiatric disorders such as anxiety, bipolar, depression, post-traumatic stress disorders, and several others. They also provide services to people with family problems, work place problems, substance abuse, stress, and relationship issues. Masters level clinicians and doctorate level clinicians also work in the same environments.