Ch4
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This document discusses the purpose and ownership of patient records in different healthcare settings like hospitals and physician offices. It covers provider documentation responsibilities like signatures, timeliness of entries, and amending records. Different types of patient record formats are described, including problem-oriented records and electronic health records. Guidelines for archiving records, record retention laws, and the roles of healthcare facilities and professionals in completing patient records are also summarized.
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Ch6
The document discusses guidelines for patient record documentation in inpatient, outpatient, and physician office settings. It outlines the general components that should be included in patient records such as patient identification, facility identification, and dated entries. Specific record forms are mentioned for things like the patient face sheet, advance directives, clinical data, and ancillary reports. The role of a forms committee in facilitating efficient documentation and ensuring compliance is also summarized.
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The document discusses the purpose and ownership of patient records in hospital and physician office settings. It covers provider documentation responsibilities like signatures, legibility, and timeliness of entries. Different types of patient record formats are described, including problem-oriented records and source-oriented records. The document also outlines how patient records are archived, retained, and destroyed according to legal requirements. It discusses the roles and responsibilities of governing boards, physicians, and HIM departments in completing patient records.
Ch5
This document discusses the evolution and components of electronic health records (EHRs). It provides an overview of computer hardware and software as they relate to EHRs. The document outlines the advantages and disadvantages of both manual and automated health records. It also discusses stakeholders in health information exchange, components of EHRs, and challenges in transitioning from manual to electronic records systems.
Ch7
The document discusses various systems for numbering, filing, storing, and circulating records in a healthcare setting. It covers numeric and alphabetic filing systems, centralized and decentralized organization of patient records, different types of filing equipment including lateral files and power filing machines, methods for numbering records, controlling filing systems, circulating records, and securing health information as required by HIPAA regulations.
HI 205 Chapter6.4ed rev6 6-18
This document discusses guidelines for patient record documentation in inpatient, outpatient, and physician office settings. It provides examples of paper and electronic formats for documentation like the review of systems. General documentation issues that are addressed include patient identification, dating of entries, and forms like the face sheet. The types of clinical data that must be documented for inpatient hospital records, physician office records, and outpatient hospital records are also outlined. Facilities should establish a forms committee to facilitate efficient documentation and ensure compliance.
Ch8
The document discusses indexes, registers, and health data collection. It describes master patient indexes, disease, procedure, and physician indexes. Registers and registries are discussed, including birth/death certificates and case report forms. Methods of case abstracting and various health care data sets are outlined. Health care data collection methods like statistics charts and ensuring data quality are also covered.
Ch3
This document summarizes various health care settings. It describes acute care facilities like hospitals that provide short-term care and ancillary services. Hospitals are categorized based on factors like bed size and specialty. The document also outlines ambulatory and outpatient care settings, alternate care facilities like behavioral health and long-term care, and federal, state, and local health care providers.
Ch9
The document discusses several legal aspects related to health information management. It defines key legal and regulatory terms like administrative law, case law, and statutory law. It also outlines various case law principles and types of subpoenas. The document also summarizes rules and legislation that govern the confidentiality, privacy, and security of patient health information, including HIPAA and conditions for the release and tracking of protected health information.
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The document discusses guidelines for patient record documentation in inpatient, outpatient, and physician office settings. It outlines the general components that should be included in patient records such as patient identification, facility identification, and dated entries. Specific record forms are mentioned for things like the patient face sheet, advance directives, clinical data, and ancillary reports. The role of a forms committee in facilitating efficient documentation and ensuring compliance is also summarized.
HI 205 Chapter4.4ed
The document discusses the purpose and ownership of patient records in hospital and physician office settings. It covers provider documentation responsibilities like signatures, legibility, and timeliness of entries. Different types of patient record formats are described, including problem-oriented records and source-oriented records. The document also outlines how patient records are archived, retained, and destroyed according to legal requirements. It discusses the roles and responsibilities of governing boards, physicians, and HIM departments in completing patient records.
Ch5
This document discusses the evolution and components of electronic health records (EHRs). It provides an overview of computer hardware and software as they relate to EHRs. The document outlines the advantages and disadvantages of both manual and automated health records. It also discusses stakeholders in health information exchange, components of EHRs, and challenges in transitioning from manual to electronic records systems.
Ch7
The document discusses various systems for numbering, filing, storing, and circulating records in a healthcare setting. It covers numeric and alphabetic filing systems, centralized and decentralized organization of patient records, different types of filing equipment including lateral files and power filing machines, methods for numbering records, controlling filing systems, circulating records, and securing health information as required by HIPAA regulations.
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This document discusses guidelines for patient record documentation in inpatient, outpatient, and physician office settings. It provides examples of paper and electronic formats for documentation like the review of systems. General documentation issues that are addressed include patient identification, dating of entries, and forms like the face sheet. The types of clinical data that must be documented for inpatient hospital records, physician office records, and outpatient hospital records are also outlined. Facilities should establish a forms committee to facilitate efficient documentation and ensure compliance.
Ch8
The document discusses indexes, registers, and health data collection. It describes master patient indexes, disease, procedure, and physician indexes. Registers and registries are discussed, including birth/death certificates and case report forms. Methods of case abstracting and various health care data sets are outlined. Health care data collection methods like statistics charts and ensuring data quality are also covered.
Ch3
This document summarizes various health care settings. It describes acute care facilities like hospitals that provide short-term care and ancillary services. Hospitals are categorized based on factors like bed size and specialty. The document also outlines ambulatory and outpatient care settings, alternate care facilities like behavioral health and long-term care, and federal, state, and local health care providers.
Ch9
The document discusses several legal aspects related to health information management. It defines key legal and regulatory terms like administrative law, case law, and statutory law. It also outlines various case law principles and types of subpoenas. The document also summarizes rules and legislation that govern the confidentiality, privacy, and security of patient health information, including HIPAA and conditions for the release and tracking of protected health information.
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The document discusses various careers in health information management, including cancer registrar, coding and reimbursement specialist, chief information officer, and health information manager. For each career, it provides information on typical training, credentials, and employment opportunities. It also discusses professional associations for various certifications in areas like coding and lists additional career opportunities in consulting, management, and other roles.
Ch1
The document summarizes key aspects of health care delivery systems, including the history and evolution of health care in the US. It outlines the continuum of care from primary to quaternary care and different types of health care facility ownership structures. It also discusses the organization and operation of health care facilities, the roles of accrediting organizations, legislation impacting health care, and important terms related to delivery and regulation of care.
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Doc-Quick is a service that matches patients and doctors to reduce no-shows and cancellations. It allows doctors to fill unused time in their schedules, saving them over $150,000 per year. For patients, it provides convenient same-day appointments and reduces wait times for procedures. Doc-Quick costs $49 per month for doctors to gain unlimited referrals, far less than traditional patient referral services. It benefits both the healthcare system and medical professionals by improving utilization of resources and lowering overall costs.
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Doc-Quick is a service that matches patients and doctors to reduce no-shows and cancellations. It allows doctors to fill unused time in their schedules, saving them over $150,000 per year. For $49 per month, Doc-Quick provides unlimited patient referrals, compared to $100 or more per referral from other services. It also benefits imaging centers and patients by reducing wait times and allowing for same-day appointments and procedures. Both doctors and patients can use the convenient app or web portal to quickly schedule appointments as openings become available.
Doc quick doctors
Doc-Quick is a service that matches patients and doctors to reduce no-shows and cancellations. It allows doctors to fill unused time in their schedules, saving them over $150,000 per year. For patients, it provides convenient same-day appointments and reduces wait times for procedures. Doc-Quick costs $49 per month for doctors to gain unlimited referrals, far less than traditional patient referral services. It benefits both the healthcare system and medical professionals by improving utilization of resources and lowering overall costs.
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Doc quick presentation
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This document discusses the purpose and ownership of patient records in various healthcare settings like hospitals and physician offices. It covers provider documentation responsibilities like signatures, timeliness of entries, and amending records. Different types of patient record formats are described, including problem-oriented records and electronic health records. Guidelines for archiving records, record retention laws, and the roles of healthcare facilities and professionals in completing patient records are also summarized.
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- There is significant opportunity to improve recruitment through more patient-centric approaches leveraging data, technology, and analytics to identify more eligible patients and improve the recruitment process. However, this will require changes to traditional models.
Patient Recruitment Strategies for Sponsors and CROs
The document provides 17 strategies for improving patient recruitment in clinical trials in order to complete enrollment faster, such as loosening inclusion/exclusion criteria, eliminating unnecessary assessments, educating referral physicians, adding more study sites, and hiring a recruitment consultant. The strategies aim to increase the number of patients screened and enrolled by streamlining processes, improving outreach and communication, and learning from high-performing sites. Faster enrollment allows medical products to help patients in need sooner and addresses a significant challenge facing the clinical trials industry.
HI 205 Chapter8.4ed rev6 6-18
This document discusses indexes, registers, and health data collection. It describes master patient indexes, disease, procedure, and physician indexes. Registers and registries are also covered, including case report forms, vital statistics like birth and death certificates. Methods of health care data collection are examined, such as case abstracting systems, common health care data sets, and descriptive health care statistics like bar graphs and pie charts. Data quality measures like integrity, reliability and validity are also addressed.
Electronic medical record for clinic
Railhealth EMR encompasses the information and capabilities required to support healthcare service delivery, where the information is captured in a computer-readable form that supports interoperability and clinical decision support.
In this presentation, you will know regarding the features, objectives and benefits by using our Railhealth EMR
Creating Data-driven Strategies to Improve Hospital Outcomes: A Case Manager'...
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The document discusses strategies for hospitals to create data-driven case management programs. It outlines a framework for hospitals to assess data needs, design analytics reporting, and use data to improve outcomes. The framework includes 4 steps: 1) assessing information needs, 2) designing future reporting structures, 3) sustaining data management and auditing, and 4) developing analytics and reporting capabilities. Key goals are providing the right data to stakeholders, enhancing decision-making, and using metrics to influence performance.New Ways to Improve the Patient Experience: Because it Begins Before the Fron...
This presentation will review strategic initiatives for revenue cycle leaders to further engage patients in their care experience – beginning before they enter the hospital’s front door. The session will present key strategies and related outcomes in patient satisfaction, staff performance, reimbursement and upfront patient collections.
• Ensure meaningful upfront encounters with Patient Access – at each and every encounter.
• Hardwire measurable standards throughout Patient Access teams.
• Reduce process time and eliminate duplication for quicker patient turnaround.
• Ensure consistent practices across hospital entities and among associates.
• Avoid financial harm through automated documentation.
• Protect staff through documentation integrity.
• Increase visibility of – and access to – critical patient touch points across the organization.
Leading the development of Texas Health’s Patient Access infrastructure, Patti Consolver and Scott Phillips oversee the centralized patient access intake center and the patient access departments for the system’s 13 wholly-owned hospitals.
HI 205 Chapter1.4ed
The document provides an overview of health care delivery systems and facilities in the United States. It discusses the history of medicine from prehistoric to modern times and the evolution of health care delivery, including the development of early hospitals and quality initiatives. It also outlines the continuum of care from primary to quaternary care and different types of health care facility ownership structures. Finally, it covers licensure, regulation, accreditation processes, and recent legislation that have shaped the U.S. health care system.
Trends in clinical research and career gd 09_may20
The document discusses trends in clinical research and career prospects. It provides an overview of clinical trials, including what they are, their guiding principles, and a brief history highlighting the first clinical trial in 1747. It then covers topics like good clinical practice guidelines, the various phases of clinical trials, and career options in clinical research. Emerging trends are also summarized, such as the movement from paper-based to electronic data collection and regulatory submissions. Overall, the document offers a high-level introduction to clinical research processes, guidelines, and associated career paths.
Practical Strategies for Taking on New Studies Post COVID-19
Hear expert guidance for ensuring readiness when opening your doors and making data-driven, evidence-based decisions on which studies to accept post COVID-19.
Cadth 2015 c6 symposiuml semchuk the rqhr perspective
This document discusses opportunities for increased collaboration across formularies in Saskatchewan's health regions. It provides context on the current decision-making processes and formularies within the Regina Qu'Appelle Health Region. Challenges include differences in coverage of drugs between regions that can impact patients who transfer between facilities. Greater alignment is needed, as demonstrated by a successful example of a provincial working group that aligned ticagrelor coverage based on clinical evidence. Overall, the speaker argues that formalizing collaboration through initiatives like joint evidence reviews and policy consultation can help standardize practices across regions to improve patient care continuity.
Similar to Ch4 (20)
Crossing the Threshold: Clinical Portals from a Site Perspective
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David Waller Interoperability Engagement Lead, NHS England
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Patient Recruitment Strategies for Sponsors and CROs
Patient Recruitment Strategies for Sponsors and CROs
Creating Data-driven Strategies to Improve Hospital Outcomes: A Case Manager'...
Creating Data-driven Strategies to Improve Hospital Outcomes: A Case Manager'...
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- 1. Chapter 4 Introduction to the Patient Record
- 2. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Purpose of the Patient Record • Ownership of the patient record • Hospital inpatient record • Hospital outpatient record • Physician office record • Alternate care settings
- 3. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Provider Documentation Responsibilities • Authentication of patient record entries – Signatures – Countersignatures – Initials – Fax signatures – Electronic signatures – Rubber stamp signatures – Abbreviations used in the patient record – Timeliness of patient record entries – Amending the patient record
- 4. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Abbreviation List
- 5. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Development of the Patient Record • Inpatient record: Admission to discharge • Date order of patient record reports • Outpatient record: handling repeat visits • Physician office record: continuity of care
- 6. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Patient Record Formats • Primary and secondary sources of information • Source-oriented record (SOR) • Problem-oriented record (POR) • Integrated record • Chief complaint, history, examination, details, drugs/dosages, assessment, and return visit (CHEDDAR)
- 7. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Patient Record Formats (Continued) • Automated record systems • Computers in health care • Longitudinal patient record • Advantages and disadvantages of manual and automated record systems
- 8. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Archived Records • Shadow records and independent databases • Record retention laws • Facility retention policy considerations • Alternative storage methods • Off-site storage • Record destruction methods • Disposition of patient records following facility closure
- 9. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Patient Record Completion Responsibility • Governing board and facility administration • Attending physicians and other health care professionals
- 10. © 2016 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Role of the HIM Department in Record Completion • Record assembly • Quantitative analysis • Qualitative analysis • Concurrent analysis • Statistical analysis