To determine financial responsibility the specialist needs to know what services are covered and are not covered under the patients plan. The patient is also explained that they will be billed whatever services the patient’s policy does not cover. Step 3 Check in patients –In step three the specialist will have the returning patient sign in, collect whatever necessary money from them co-payment or for an outstanding balance from a prior visit, copy or scan their current insurance card. Have the patient read and sign any new/important forms that pertain to the patient (authorizing any planned procedures and payments). Step 4 Check out patients – Even though the specialist is to give the patient all prescriptions, lab slip or referral paperwork they might need and set up a follow up appointment if necessary.
By providing an efficient intake process, a certain flow can be maintained to move the process along smoothly and more organized. If any of the processes are not organized there will be a lot of confusion and unhappy patients. Patient satisfaction should be a step that is included in any health care facility. The patient intake process usually began when a patient calls to schedule an appointment. This is usually where the patients personal information is obtain such as their name, phone number, date of birth, address, reason for the appointment, name of health care coverage and referring physicians if there is any.
Review the labs, and ensure any lab values that need follow up are faced or phoned to the surgeon. • Ensure any day of antibiotic orders have been faxed to pharmacy, take any actions you can for pre operative orders now. • Phone the patient, fill out any other information you can on the pre-op check list. Make sure you cover all the points on the telephone check list sheet, this way our patients will arrive with a ride home, and someone to stay with them post OR. • Once the Telephone screen is complete – on the upper left hand part of the chart write
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.
The Importance of Proper Chart Documentation Introduction One of the most important things you will do in your job in the healthcare profession is charting. Charting is the way healthcare professionals communicate a patient’s weight, height, condition, medication, and past medical history. As soon as you walk in a doctor’s office, hospital, or any medical facility charting begins from the moment you sign in. Only healthcare professionals that are certified, licensed, or registered to chart should do so. There are three reasons proper chart documentations are important: to avoid lawsuits, keep accurate medical information for patient, and to maintain proper communication from one professional to another.
These revisions have streamlined the performances, the standards of care for patients and eliminated certain requirements. Accuracy of patient identification by using two patient identifiers is to facilitate health care providers in patient identification. They accomplish this by asking name and date of birth ensuring they have the right patient. Improvement of communication to patients by expediting test results can enable them in serious health care decisions. This can alleviate their stress about tests that might involve threatening diseases.
INTRODUCTION On admission to a healthcare facility, a health assessment is a mandatory tool in assessing the patient’s health status. In general an assessment is broken down into two types of reviews, by conducting a health history which includes the collection of subjective data (information elicited by the patient or patients’ family members) and a physical examination of the patient which includes the gathering of evidence based data (Wilson & Giddens, 2009). Collecting and documenting accurate information is imperative in providing the allied health team this information to facilitate an efficient and well-formed care plan in addition to establishing a baseline for subsequent assessments (Springhouse, 2004; Wilson & Giddens, 2009). PATIENT INTERVIEW A health assessment should consist of establishing a patient profile and incorporate a full medical history (Harvey, 2004). The traditional approach includes collecting subject matter on “biographical data, present health concerns (or present illness) and the chief complaint, past history, family history, review of system and patient data” (Farrell & Dempsey, 2010, p. 74).
Health Information Exchange Professor Crossley Ebony Drummond October 21, 2013 Health Information Exchange The Electronic health information exchange helps medical professionals such as Nurses, doctors, pharmacist and other health care providers. This system also allows patients to properly access and safely shares the patient’s medical records efficiently, bettering speed, quality and the cost of patient care. Electronic health information exchange cannot replace intercommunication between the patient and the patient’s physician, but it can greatly improve the completeness of patients medical record in which cam effect the care positively, current medications and other information that is carefully abstracted during visits. Sharing patient records properly will better inform decision making at a certain point of care. This can allow providers to avoid re-admission, avoiding medication errors, lower duplication testing and improve diagnosis.
These abbreviations certainly save time and can expedite care, but they can also cause a multitude of problems. Abbreviations for differing medicines can be mistaken, Medical errors are typically caused by illegible writing and misrepresentations of some types of abbreviations when providing treatments or filling a prescription. As a result health care agencies, such as the Joint Commission on Accreditation of Healthcare Organizations have required hospitals and other medical facilities to create a list of unacceptable abbreviations. Many facilities are also discouraging the use of abbreviations in medical records and documentation. Standardization is paramount and will require practice changes for all healthcare providers.
Notions of apprehension and fear of a paperless system is brought to the fore front by those who are deemed to commission the latest and greatest EMR technology. Medical Record Security State laws are specific on the access to patient’s records to only those authorized to do so. A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. What information should be protected, How to deter security as well as how to keep this organization patient’s records safe.