Carol Alborn HIM CORE Day 11 9/12/2011 Purpose and Function of the Health Record A health record is a virtual storage place that documents health care services from healthcare providers at various locations such as the DR.’s office, nursing homes and ambulatory service locations. It’s made up of data or facts from the patient and family members, and these healthcare services, which is analyzed for useful information. It is the HIM professional’s responsibility to take data from traditional practice forms and any Personal Health Record (PHR) or from any other sources, then enter data into the Electronic Health Record (EHR) system. Anything missing can alter the patients care. Its Primary purpose is to ensure quality patient care and managing the cost of that care.
A key attribute of medical model is the development of companion diagnostics, which measure levels of proteins, genes or specific mutations are used to provide a specific therapy for an individual's condition by stratifying disease status, selecting the proper medication and tailoring dosages to that patient's specific needs. Additionally, such methods can be used to assess a patient's risk factor for a number of conditions and tailor individual preventative treatments. Stratified medicine has been used for the current approach. Examples of successful personalized treatments exist in the field of oncology.
Medical Imaging Keiser University Medical Imaging Medical imaging is a discipline within the medical field which involves the use of technology to take images of the inside of the human body. These images are used in diagnostics, as teaching tools, and in routine healthcare for a variety of conditions. Medical imaging is sometimes referred to as diagnostic imaging, because it is frequently used to help doctors arrive at a diagnosis, and there are a number of different types of technology used in medical imaging. The goal of medical imaging is to provide a picture of the inside of the body in a way which is as non-invasive as possible. An imaging study can be used to identify unusual things inside the body, such as broken bones, tumors, leaking blood vessels, and so forth.
When treatment occurs, x-ray beams are directed very accurately to the relevant areas of the body using highly sophisticated machinery. Reliable and accurate knowledge of the tumour site, surrounding structures and its extent is essential in order to avoid the risk of inadequate dosage. The planning stage has to be accurate because any data obtained at this stage, if they are any errors, will be propagated during the course of treatment. This is also because the way the patient would be set up in terms of how they will be lying on the couch and any equipment used, will be how they would be set up day to day during their treatment. This would be different for each individual in terms of the immobilisation, set up, dose distribution, the size and shape of the beam, and patient positioning.
While this might sound easy, proper documentation requires diligence by everyone involved as this data provides critical information for tracking processed instruments to the patient and assessing the reliability of the sterilization process. Sterilization documentation is used when instruments need to be recalled in the healthcare facility and determining the reason for a sterilization process failure. Documentation provides a permanent record that you’ve done everything you said you did, from cleaning to sterilization to instrument distribution. Simply put, documentation established accountability. An important aspect of quality control, this part of documentation or record keeping documents each item or instrument that is processed, assists in proper stock rotation, establishes accountability, and assists with recalls.
This is addition to movement away from or towards these planes. This approach is often used in describing what is happening in the body and where. For example when a patient enter the emergency room and describing pain or an injury, the health care professional can document and relay information in a more precise way to others important to the patients care. It is also useful when reading important scans like a CAT scan which provides cross sectional views of all types of tissue. Knowing what plane a specific image was taken can help diagnose and locate conditions like cancer, blood clots, and kidney disease.
Health Insurance Specialist Latasha Roberts MO205 Insurance Claims, Processing and adjudication September 9, 2012 Health insurance specialists carry many different responsibilities, which include reviewing patient records using medical coding procedures. Health insurance specialists are also responsible for detecting any coding errors or performing any modifications needed. Other responsibilities include assisting patients in obtaining and understanding medical benefits. In the office, communication with other medical staff members and health insurance providers often occur. Health insurance specialists are responsible for processing medical insurance claims, medical coding and
ANAESTHETICS Preoperative assessment 1. Aims • The preoperative evaluation consists of gathering information on the patient and formulating an anesthetic plan • The overall objective is reduction of perioperative morbidity and mortality • Ideally, the preoperative evaluation is done by the person who will administer the anesthesia. The anesthetist should review the surgical diagnosis, organ systems involved, and planned procedure • Through interview, physical exam and review of pertinent current and past medical records, the patient’s physical and mental status are determined • All recent medications are recorded and a thorough drug allergy history is taken • The patient should be questioned about the use of cigarettes, alcohol and illicit drugs • The patient’s prior anesthetic experience is of particular interest – specifically, if there has been a history of anesthetic complications, problems with intubation, delayed emergence, malignant hyperthermia, prolonged neuromuscular blockade, or postoperative nausea and vomiting • Informed consent is the communication of the anaesthetic plan, in terms the patient understands, and covers everything from premedication, preoperative procedures, and intraoperative management, through the recovery room and postoperative pain control • The alternatives, potential complications, and risks versus benefits are discussed, and the patient’s questions are answered • In summary, pre-operative care aims to ensure that patients: o Get the right surgery o Are happy and pain free o Are as fit as possible o Have individual decisions on type of anaesthesia/analgesia taking into account risks, benefits and wishes 2. Pre-operative History • Have the symptoms, signs or patient’s wishes changed? • Assess cardiovascular and respiratory systems, exercise tolerance, existing illnesses, drug therapy and allergies • Assess
For the Technical Communications Rhetorical Analysis assignment, I have reviewed two instructional documents. The first document is an instructional document for patientsreceiving steroid pulse therapy for the treatment of autoimmune diseases and the effect of instruction on patient knowledge by Yu-Chu Pai who works for BioMed Central Ltd. The second document is also a letter about blood transfusion errors by American Society of Registered Nurses. The purpose of this memo is to outline the similarities and differences that I have discovered during my rhetorical analysis of these two pieces. I will provide an audience analysis and a situational analysis, along with a discussion of the conventions and appeals of the two project proposal documents.Audience
The first part of Radiology that is important is the technology that one has to use in order to observe inside the body. One instrument used in Radiology is a Computer Axial Tomography Scan or a CAT scan. This tool is used by Radiologists to create an image of inside the human body in horizontal pieces. Another Instrument they use is Echocardiography Machine. This is used to perform heart sonography to understand its function and condition.