CheckPoint - Medical Records Documentation and Billing Barbara Batten HCR 220 Version 3 August 31, 2012 Talithia Graham CheckPoint - Medical Records Documentation and Billing Compliance plans correlate with the varied standards of medical records and their documentation by applying, correcting and preventing any illegal medical practices. When a medical facility or organization has a compliance plan in place, all policies and practices are implemented. They provide ongoing staff training and refresher courses and watch for detection of problems that might occur. They can be assured that they are keeping within all compliance does when it comes to medical records and documentation. If all ten steps of the medical billing process are followed, then a facility can have the assurance that they will stay within compliance of the proper guidelines.
However, a medical biller and coder will be aware of what goes on inside of the office or hospital room, just not hands on. Their job is just as important as the doctor's because it includes analyzing the operations to relay to the insurance companies in a form of codes (Infotech, 2014). A medical biller and coder has a job that leaves no room for error, and organization is the key for maintaining a successful and efficient work environment. When a patient visits the doctor, emergency room, clinic, or hospital, their visit is recorded from the time they check in until even after they leave. Vitals, symptoms, diagnosis, prescription, and post care are all significant information that must be noted to ensure that the patient’s insurance company know what they are paying the doctor for.
They also need to know how to manage patient records, work with medical billing and coding, and how to manage the day-to-day workings of a medical office. Medical office management programs are designed to teach all these skills. Most Universities include the following courses designed to prepare a student for the field. They include Medical Law and Bioethics, Medical Terminology, Anatomy and Physiology, Medical Office Management, Medical Insurance and Billing, Medical Coding, Medical Office Accounting, Healthcare Professionalism, Medical Records Management, and Medical Office Applications, among other courses. At the end of the program all students are required to do an externship so that they may get experience before entering the
In many physicians’ offices now days, it is common to find compliance codes on the physical form that is filled out by the physician. This process only helps to make sure that as few mistakes as possible are made in the coding and billing process. One of the most important factors in the coding process is accurately matching diagnoses and procedures, in order to avoid any possibilities of a claim being rejected. This is also important in the assurance of reimbursement to a medical professional for correct procedures. If an incorrect procedure is sent for billing, the result could be a physician being delayed a payment, or, missing out on payment altogether.
Communication is needed for people to keep in contact with family/friends, either verbally, letters/email or face to face contact. To arrange everyday activities we need to communicate. We need this form of communication to enable us organise around the individual and their choices, so that they can choose to like or dislike a person. Any changes in care plans are passed over to all staff, in order for staff to have a consistent approach with all service users. Any medical changes must be documented on a record sheet, marked on the meds chart, and passed over by hand in the communication book.
Communication Opinion Paper HCS 320 Communication Opinion Paper Today the healthcare is more diverse and complex and improving the communication among the healthcare professionals can help in the safe delivery of the patient care. Effective communication is the basic element of the communication. A better medical care depends upon the effective communication between the patients and the staff of the medical care. Ineffective communication can result in the delayed or improper treatment of the patients. Effective communication which is always timely, accurate, unambiguous and is easily understood by the recipient helps in reducing the errors and results in the complete safety of the patient.
She analyzes patients’ medical history, performs physical assessments, and educates about the implication of radiation, symptom and management of the disease and its consequences. Mrs. White is a member of a radiation oncology team at Boston Medical Center. Her role is to educate and support patients and their families through all aspects of their care (Shea et al, 2010). Mrs. White works in connection with the oncology resources at the local clinic and with a local community for nutritional care, home care, and support resources. According to her the medical diagnosis is hard to change most of the time, but it is very important to impact the patient and family physically, psychologically, socially, and spiritually.
Important information is shared through electronic medical records (EMR). Having a system that shares this information ensures that each member of the patient care team not only has all of the information but also has accurate information. Many times the historian in a patient interview is not the patient but a friend or family member. Without a direct line to the source of the information medicines get left off the list, surgeries get forgotten, and life threatening allergies are overlooked. With the implementation of an EMR patients will receive accurate treatment plans based on practitioners having the all the information needed to make critical
These individuals also work closely with patients by taking vital signs, taking notes in medical charts, etc. A job in this field is very versatile because you can work in any number of medical specialties. Educational Requirements In order to become a medical assistant and attend a medical assistant training school, you must have graduated from high school. There are two kinds of educational medical programs for those wishing to work in this field. Some schools for medical assistants offer a one-year certificate program.
The tree things that will define the scope of practice for me are my education/training, institution, and governing body. 4. Based on the Code of Ethics for your chosen healthcare profession, list and explain three standards of professionalism. Three examples of the standards of professionalism are 1) A physician shall support access to medical care for all people 2) A physician shall respect the law 3) A physician shall continue to study/advance scientific knowledge. In reference to number 1, physicians are morally obligated to seek medical care for all sick people.