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.
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.
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
The records contain information that is used for different purposes: 1) Administrative tasks: Registering patients Scheduling appointments 2) Clinical practices (diagnostic & therapeutic decisions): Computerized prescriptions Lab tests Diagnostic measures Progress notes from different healthcare providers 3) Research practices QUALITY BENEFITS OF AN EMR Assessing data from paper medical records is time-consuming because it involves reviewing information manually — record by record. By contrast, an EMR makes data easily accessible and enables physicians to use their own data to improve quality of care. With efficient electronic access to clinical data, practices can systematically improve the quality of care in a number of areas: • Enhanced patient education materials Practices can customize information packets and Web site referrals for patients so that patients receive essential information about their health at the point of care and guidance from reputable, scientific sources. • Quicker turnaround times for results of lab tests and imaging studies Connectivity between practices and the clinical laboratories and imaging centers shorten the time necessary for diagnostic information to reach the practice and the patient. Physicians can initiate therapy
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.
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.
Interdisciplinary care also increases the efficiency and safety of the patient's care. A way to promote interdisciplinary care is to hold staff meetings once a month. As the supervisor for the clinic the staff needs to be aware of available resources and changes in the clinic. If staff members are not present during these meetings then minutes of the meetings should be provided. The staff members of the clinic should sign off that they received the minutes and thus be informed.
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.
The EHR is a computerized electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates the clinician's workflow and has the ability to generate a complete record of a patient encounter - as well as supporting other care-related activities directly or indirectly, including evidence-based decision support, quality management, and outcome reporting. In this paper I will discuss the many benefits and drawbacks of EHR’s, the types of software used and their functions as well as my thoughts on the future of Electronic Health Records. Many healthcare organizations have switched over to electronic health records since President George W. Bush called for health records to be stored electronically by 2014, and President Obama’s administration plans to continue pushing for that deadline.
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).