This document discusses medical records security and privacy. It covers how medical information is critical for patient care, billing, and administration. However, medical records also contain highly sensitive personal information that must be kept private and secure. The document outlines several security problems at hospitals, including disparate systems, uncontrolled access, and abuse of access. It discusses the need to carefully control access to patient data for various roles. Principles of medical records privacy and regulations affecting patient privacy are also covered. The document argues for improved security through education, dedicated resources, and technologies like tokens or facial recognition.
2024 CPT® Code Updates (HIM Focused) - Part 2Health Catalyst
Each year the CPT code set and the HCPCS code set undergo significant changes, and your coding staff needs to be aware of the changes in order to ensure a smooth transition into 2024. Join us for a discussion of the new, deleted and revised CPT codes and associated guidelines for 2024. This is part two in a three-part series.
During these complimentary webinars, we will empower you to correctly apply the new and revised codes and discuss the rationale behind this year’s changes. This presentation will be geared towards hospital staff with a focus on the surgical section of the CPT book in addition to surgical Category III codes.
This document discusses medical records security and privacy. It covers how medical information is critical for patient care, billing, and administration. However, medical records also contain highly sensitive personal information that must be kept private and secure. The document outlines several security problems at hospitals, including disparate systems, uncontrolled access, and abuse of access. It discusses the need to carefully control access to patient data for various roles. Principles of medical records privacy and regulations affecting patient privacy are also covered. The document argues for improved security through education, dedicated resources, and technologies like tokens or facial recognition.
2024 CPT® Code Updates (HIM Focused) - Part 2Health Catalyst
Each year the CPT code set and the HCPCS code set undergo significant changes, and your coding staff needs to be aware of the changes in order to ensure a smooth transition into 2024. Join us for a discussion of the new, deleted and revised CPT codes and associated guidelines for 2024. This is part two in a three-part series.
During these complimentary webinars, we will empower you to correctly apply the new and revised codes and discuss the rationale behind this year’s changes. This presentation will be geared towards hospital staff with a focus on the surgical section of the CPT book in addition to surgical Category III codes.
12. 功能一覽表
入院護理評估
Vital S ig n ( 成人 , 兒童 , 產 高危跌倒評估 醫囑查詢 工作清單
科 , 精神科 , 新生
In take /O u tp u t 兒) 護理摘要 /
高危跌倒評估列表 個人病患
交班單
護理計畫
G C S & 肌力
預防跌倒措施檢查表 出院準備篩檢表 派班作業
護理指導
各項圍長
預防跌倒措施檢查
列表 出院評估 病房日誌
Vital S ig n S O AP 護理記錄
密切量測 護理診斷 / 目標 /
給藥記錄 物理約束評估 出院衛教
措施使用率
管路管理 ( 藥囑執行 / 取消 )
病房待執行 物理約束記錄 電訪記錄 病歷完成率
特殊註記事件
給藥查核
TPR S h e e t 壓瘡危險因子評估 管路使用量統計
每日疼痛評估
血糖及胰島素記錄 傷口 / 壓瘡護理記 疾病嚴重度統計
初始疼痛評估 錄
胰島素部位設定
持續疼痛評估
12
13. 生理監測功能 ( 一 )
Vital S ig n 以點選式輸入方式，降低謢理人員使用鍵盤的心理障礙
，提供系統的友善度。
護理人員可以簡單的登錄資料，且可將資料導到護理記錄中，避
免護理人員重覆抄寫，使資訊一致性。
13
14. 生理監測功能 ( 二 )
異常量測值可即時顯示，除顏色區別以提醒護理人員外，並動態提
供護理處置資訊以協助護理人員決策。
無法量測 Vital S ig n 時，提供無法測量原因，以避免醫療糾紛。
14
15. 生理監測功能 ( 四 )
提供日期區間查詢 Vital S ig n 、 I/O 、 C o m a S c ale 、 C VP/B W 等
記錄，使記錄完整表示，並可呈現 Vital S ig n 趨勢圖以了解病患病情
。
提供即時查詢功能，登錄資料一致性的資訊可強化醫師、護理人員等
臨床醫療處置決策。
15
