This document discusses the importance of medical record keeping and provides guidance on the key components and structure of a medical record. It emphasizes that the primary purpose of medical records is to serve the physician's memory and communicate information to other providers to facilitate quality patient care. The document outlines the standard sections of a medical record including identification information, chief complaint, history of present illness, past medical history, review of systems, medications, allergies, physical examination, assessment, and plan. It provides details on what should be included in each section to fully document a patient's medical history and care.
Medico Legal implication of medical records-IndiaSrishti Bhardwaj
Medico legal liabilities related to patient records,
Medical Record committee and role of committee Hospital Utilization
Bed turnover ratio,
Average length of stay,
Death rate,
Bed occupancy rate
Unit 4- BVUCHMSR Portion (Sem-3)
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Medico Legal implication of medical records-IndiaSrishti Bhardwaj
Medico legal liabilities related to patient records,
Medical Record committee and role of committee Hospital Utilization
Bed turnover ratio,
Average length of stay,
Death rate,
Bed occupancy rate
Unit 4- BVUCHMSR Portion (Sem-3)
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Medical Record system: training to staff, maintenance & Retention & StorageSrishti Bhardwaj
Developing recording system in the hospital:
Maintaining adequate records on the patient file,
Training programs for staff,
*Retention and storing of medical Records*:
Outpatient,
Inpatient,
Medico legal cases retention policies,
process of medical record storing
This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.
Lecture 13 privacy, confidentiality and medical recordsDr Ghaiath Hussein
A lecture on privacy, confidentiality and medical records delivered to Alfarabi Medical College undergraduate medical students in the week starting 27.11.2016
Healthcare and similar industries have stringent regulations and requirements when managing patient records and documents. Learn how you should handle these files and the proper ways to destroy them when their retention periods are up. For additional information, check out www.shrednations.com.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Medical Record system: training to staff, maintenance & Retention & StorageSrishti Bhardwaj
Developing recording system in the hospital:
Maintaining adequate records on the patient file,
Training programs for staff,
*Retention and storing of medical Records*:
Outpatient,
Inpatient,
Medico legal cases retention policies,
process of medical record storing
This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.
Lecture 13 privacy, confidentiality and medical recordsDr Ghaiath Hussein
A lecture on privacy, confidentiality and medical records delivered to Alfarabi Medical College undergraduate medical students in the week starting 27.11.2016
Healthcare and similar industries have stringent regulations and requirements when managing patient records and documents. Learn how you should handle these files and the proper ways to destroy them when their retention periods are up. For additional information, check out www.shrednations.com.
The goal of patient interviews is to develop a therapeutic relations.docxrtodd194
The goal of patient interviews is to develop a therapeutic relationship and make a diagnosis. A therapeutic relationship comprises the healthcare provider and patient feeling comfortable with each other. The patient comes to the interview to seek relief from an illness, while the healthcare provider understands the patient's problems to provide a remedy. They trust that the care provider will listen to the issues and offer them comfort and confidence (Dang et al., 2017). Diagnosis involves an evaluation of the patient's signs and symptoms. The care practitioner obtains information on the patient's signs and symptoms by asking specific questions. At the end of the interview, the practitioner comes up with a differential diagnosis to determine appropriate treatment options.
The healthcare provider needs to follow specific interview guidelines. For instance, the interview setting ought to be comfortable, free from disturbances, and discreet. Besides, the questions should be open-ended, focused, and specific to allow patients to express themselves. Also, the care provider needs to ask the patient for clarification and make further explanations. Additionally, the healthcare practitioner ought to be emphatic and pay attention to the patient's emotional responses.
Healthcare providers are likely to make mistakes when providing care for students. I remember an incident where I used an improper technique to measure a patient's blood pressure. The patient was a teenager who had fainted at the school playground. I put the sphygmomanometer on the patient's arm without removing his sweater. Due to this mistake, the patient's blood pressure measurements increased by 40 points. The overall high blood pressure points seemed odd since there was no history of blood pressure or anxiety. While retracing my steps, I identified that the patient had his sweater on, which explained the elevated pressure. The incident made me learn that staying calm during emergencies is significant.
Medical history refers to a report that has the medical recollections and concerns of a patient. The critical components of a patient history are chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). Chief complaint or concern refers to the patient's primary reason for a visit, such as persistent headaches. HPI is the patient's comprehensive details of the chief complaint and the symptom progression (Mathioudakis et al.,2016). For instance, constant headaches for one week, causing dizziness. The ROS involves a list of questions that seek to obtain further information on the patient's additional symptoms or previous and current problems. Lastly, the PFSH comprises information on the patient's previous illnesses, medications, and incidence among family members.
Healthcare providers should be culturally competent when providing care. Doing so will prevent misunderstandings and barriers from caring. I have e.
History Taking
1.Name, age, sex, marital status, occupation, address (Demographics)
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history
see attachments I have complete a portion of the assignment but needPazSilviapm
see attachments I have complete a portion of the assignment but need the rest of the
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about c ...
THESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT- HISTORY TAKING IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM,#historytaking,#communicablediseases,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE,#HEALTHPROBLEMS
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
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