These forms are for the patient to sign stating they acknowledge their rights under HIPPA and the Medicare acts. There are the demographic forms, or registration forms, that state a patients full legal name, birthdate, gender, address, phone number, emergency contacts, and person responsible for billing. They also contain the insurance information of said patient. There are diagnostic and test results forms, to help keep track of the necessary treatments and tests a doctor has already performed and treated for. The records contain medication forms, that keep a list of past and current prescriptions.
Effective communication is important to get information from patient or staffs. Actually experience, skill, condition of the patient, health care environment, and the system of communication plays an important role for the treatment of the patient. Communication skills are crucial in the health care setting. Usually right after we visit the patient for the first time, we can figure out his or her mood and general health condition. According to that we can investigate the problem and take action to resolve it.
When the back office medical assistant gets ready to room a patient he or she has to make sure that all of the patient’s medications are up to date and all of the incoming notes and consults are also included in the chart. These things are vital for the physician to see the patient. All of these things are needed supplied for the physician to properly diagnose the patient for his or
Documentation needs to be relevant and have important information included, without going into the color of the patient’s shoes. Documentation is one of the most important responsibilities of all health care providers. It’s a means of communicating among health care team members and the primary way by which nurses record factual information about a patient’s status and the care provided – from the time of admission to follow-up after discharge (Lippincott 2007). The importance of documentation is critical. As stated before it is a legal document.
A. Advance Quality Patient Care Patient quality of care can be advanced throughout the hospital by active participation of staff with the use of nursing-sensitive indicators. It can be accomplished by educating staff of what nursing sensitive indicators are, how they help improve the quality of care, and how they impact nursing care. For example, pressure ulcer incidence is one of the indicators, and it involves the amount of ulcers that develop during patient hospital stay (Agency for Healthcare Research and Quality, n.d.). The staff should know that it is an indicator and needs to be reported to the appropriate personnel so that it can be tracked.
Awareness of Reducing Medication Errors in Nursing Practice Promoting patient safety and recovery are the goals that allied health professionals focus on when rendering medical services. However, mistakes happen everywhere, anywhere in the world in any professional field, but specifically in nursing practice. Reports reveal that patient safety issues are getting worse (AHRQ, 2009). In the medical field, the pathway of medication prescription to administration is a high risk activity not only for nurses but also for physicians and pharmacists, but the key clinician that is most prone to these medication errors is the nurse. Why is it so?
Objective data is measured during the physical examination; it can be seen, heard, smelt, felt, observed, tested or measured against an excepted standard, including: skin color, bowel sounds, blood pressure, temperature, level of pain, urine analysis etc. (Berman et al, 2010) Once vital information has been collected it must be organised, complete, factual and accurate to provide a complete picture of the patient’s past and present health, environment, strengths, coping skills and doing the right things to stay well for nursing interventions to be effective. (Jarvis c, 2008) The final stage of the assessment process is to document the patients data, this can be written or computerized and becomes the patients history. (Berman et al, 2010) 2. Explain the possible benefits of using a
Rights of Medication Safety Medication plays a key role in healthcare but can also be an important key cause of medical error. Patients are entitled to receive safe care including receiving the correct medications. The administration of medication is a daily routine for nurses therefore, it is vital to remember the “Five Rights” of medication safety. Many different things can go wrong when it comes to the administering medication, for example communication between the patient and the nurse could go wrong, or the labeling of the medication, even the dosage can cause improper usage of the drug. The question is what role do nurses play when it comes to medication safety?
A medical assistant is the first person that the patient would see. A medical assistant is like the middle man between the doctor and the patient. A medical assistant shouldn’t be confused with a physician assistant. A medical assistant would have to be able to translate the medical terminology into terms that the patient would be able to understand. When a patient or doctor gives a medical assistant information, the medical assistant should repeat it back to them to make sure that the information they have is correct.
Everything you do in the office is a reflection on the facility. It is important to take a patients vital signs in order to keep the patients history updated since the last time he/she has visited. Also, you need to establish the patients’ current health.