Its Primary purpose is to ensure quality patient care and managing the cost of that care. Its secondary purpose as defined by the Institute of Medicine (IOM) deals with individual users for education, regulations, policies and public health from data entered, verified, corrected or analyzed directly or indirectly. Homeland Security has recently been added to the list of users, including patient care providers, managers and staff, coders and patients themselves. Patients can make changes as necessary. Other users might include lawyers, employers, law enforcement and researchers.
SPC Kimberly West SGT Monika Woodard The Importance of the Proper Documentation of Biological’s in the Sterilization Department A question that often comes up in discussions about record keeping is “What type of documentation do we need to keep for our steam sterilization process, and how should information be recorded?” It is important to know not only what to document, but also the purpose for retaining pertinent information. Record keeping or documenting the biologicals is an essential component of an effective sterile processing department’s quality assurance program. Whether the sterilization process is being done in a hospital’s SPD or Operating Room, essential information needs to be documented. Documentation, also commonly referred to as record keeping, documents materials that have been processed and the results of the sterilization process monitoring. 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.
These responsibilities requires a manager to gather information from physicians and other staff members. With all the information coded and on file, a manager will be able send out accurate billing statements to insurance companies and patients. In order to be successful in the accuracy of medical records, coding and billing, and insurance processing, students who are seeking an Associates of Applied Science in Medical Office Management must acquire detail oriented skills. Mastering this skill will not only further ones career, but help simplify their responsibilities and keep them organized. According to Kaplan University (n.d.), medical office managers must be competent in medical records management, billing and coding, and insurance processing.
Project 1 There are many confidentiality, privacy and security issues that relate to working as a medical receptionist in a medical practice. It is very important to have a senior person to oversee all administrative functions. A senior person will outline the tasks your job entails and will teach you the practice’s policies and procedures. They will teach you how to access patient records and how to know what information is relevant to your work. A senior person will also check your work and will be there for guidance if any conflict of interest occurs.
Circulating nurses manage the care of the patient undergoing surgery, they assist anesthesia, monitors for breaks in sterility technique and assists with the needs of the surgeon. Scrub nurses work directly with the sterile field and the surgeon, the pass instruments and items needed for surgery. Perioperative nursing takes into account the metaparadigm of nursing, which consists of the persons, environment, health, and nursing. Person in perioperative nursing refers to be patient and the patient’s family. According to Neuman’s Systems Model, the person is composed of psychological, sociocultural, physiological, developmental and variables (Creasia & Friberg, 2011).
For these reasons there’s the need for Clinical decision support system (CDSS) to support the physicians in making right clinical decisions. Defining Clinical decision support system (CDSS) Clinical decision support system (CDSS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. [1] CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools. This paper will discuss the need for CDSS in the health sector particularly on clinical tasks.
(Crisp & Taylor, 2009) 2. What does duty of care mean in relation to health care? In the health care industry we have a duty of care to our patients. We have a duty of care to ensure the well being of our patients. We do this by following the guidelines set out for us.
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
The Health and safety executive is the main person responsible for ensuring that the legislations put in to place in the work place is enforced. The legislations in place can differ to individual work places. The Health and safety act 1974 have stated that all work places should have safety policies in place, these should entail expected standards that need to be in the work place. If the care setting was that of a hospital the policies would include manual handling of patients. There are certain rules nursing staff have to follow to ensure patients are manoeuvred correctly.
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).