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Medical Records Case tudy
ection I (Introduction) -- Liam O'Neill and William Klepack, the authors of Case tudy # 3, Integrating Electronic Medical Records and Disease Management at Dryden Family Medicine, begin their published findings by introducing readers to the concept of electronic medical records (EMR). The authors immediately narrow their focus to the adoption and implementation of EMR by Dryden Family Medicine, a rural family practice located in upstate New York, and explain that "for smaller group practices, electronic medical records (EMR) adoption is a huge undertaking that poses significant risks" (O'Neill and Kleback, 2010). The Introduction section then covers the multitude of obstacles encountered by small group practices attempting to convert to EMR, including the limited information technology experience possessed by most staff members, and the constant concern of budgetary constraints. Finally, the authors seek to clarify the emphasis of their study by stating that their focus remains…
Section III (The Vendor Selection Process) -- This section covers the process employed by Dryden Family Medicine to direct the transition to EMR. The authors begin with the steering committee established in 2002, which was "composed of one physician, the office manager, the nursing supervisor, and the front-desk supervisor" (O'Neill and Kleback, 2010). The issue of vendor fallibility is explored, as the choice of an unprepared or unskilled billing systems provider could easily undermine the practice's 50 years of record keeping. Finally, the reader is guided through the EMR vendor selection process, from the industry trade journals to consultations with fellow family practices that have previously implemented EMR systems.
Section IV (Stages of EMR Implementation) -- This section includes a detailed timeline of the EMR implementation process utilized by Dryden Family Medicine. Found in Table C3.1 and Figure C3.1 are various benchmarks in the EMR adoption process, such as "August 2003 Prescriptions generated electronically and faxed to pharmacies" and "March 2005 Patient education literature is scanned into the system and linked to EMR" (O'Neill and Kleback, 2010). The informative tables are followed by a thorough analysis of the three-stage process used to effectively introduce EMR strategies to Dryden Family Medicine's overall system. The section concludes with a concrete example of EMR-based improvements, as the authors recount a 2005 incident involving the painkiller Bextra and a Food and Drug Administration recall that patients were notified about immediately.
Section V (Impact on Job Responsibilities) -- The purpose of this section is to determine the impact of implementing an EMR system which clearly "resulted in changes in the job descriptions and responsibilities of all members of the practice" (O'Neill and Kleback, 2010). The authors observe several instances involving physician's problematic interaction with
Electronic Medical Records
Electronic Medical Record (EMR) keeping can definitely add efficiency into the modern healthcare system. However, this efficiency might be associated with some hidden costs. One example of such a cost will be due to the loss of privacy that is allowed by shared records. Not only will doctors be able to see your entire medical history, but other agencies that you might not want to share information with will have access as well. Therefore, there are both advantages and disadvantages associated with the move to a digital system.
"Imagine a world where everything important about a patient is known to the physician the first time that patient presents," says Andrew Rubin, vice president for NYU Medical Center Clinical Affairs and Affiliates in New York City (Mann, N.d.).
Doctors have full access to a patient's medical health history has the potential to reduce errors and improve patient…
Mann,, . D. (N.d.). Technology Plays Key Role in Health Care Reform. Retrieved from WebMD: http://www.webmd.com/health-insurance/technology-plays-key-role-in-health-care-reform
The master patient index (MPI) value was mainly liked by the personnel in the medical record section.
The Golden 90s
Equipped with MPI and record-keeping growth, software designers sustained to generate and progress with a new emphasis on individual hospital sections. Auxiliary department purposes, for example radiology and laboratory showed to be fairly adaptive to software that is fresh and innovative, and computer healthcare applications start to show on the market. Patient test outcomes that instigated in the laboratory and radiology department now too were obtainable via computers nonetheless again with limit as the outcomes were separate and were not linked to one another, or to any other software for instance that being done with the patient registration. A lot of these applications had basically been marked as "source" governments, and they were not courteous to assembly athwart the healthcare aptitude. This is the state that mechanization in healthcare found…
Holden, R.J. (2011). Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety. Cognition, Technology & Work, 13(1), 11-29.
Kaliyadan, F., Venkitakrishnan, S., Manoj, J., & Dharmaratnam, a. (2009). Electronic medical records in dermatology: Practical implications. Indian Journal of Dermatology, Venereology and Leprology, 75(2), 157-61.
Kochevar, J., Gitlin, M., Mutell, R., Sarnowski, J., & Mayne, T. (2011). Electronic medical records: A survey of use and satisfaction in small dialysis organizations. Nephrology Nursing Journal, 38(3), 273-81.
Kurbasic, I., Pandza, H., Masic, I., Huseinagic, S., Tandir, S., Alicajic, F., & Toromanovic, S. (2008). The advantages and limitations of international classification of diseases, injuries and causes of death from aspect of existing health care system of B&H. Acta Informatica Medica, 16(3), 159.
Each individual/entity in this scenario has an agenda. Sandra: is a child under both State and Federal Law; her immediate concern is hiding her sexual abuse by her stepfather; however, hospital administration must be concerned with her best interests on three counts: first, because she is a patient; secondly, because she is a child; third, because she is an allegedly abused child. Mrs. Anderson: is both the patient's parent and a mid-level hospital administrator; her immediate concerns are obtaining and editing medical records to keep her family together on religious grounds; however, the patient's best interest, both as a patient and a child, conflict with Mrs. Anderson's concerns. The hospital: is bound by both Federal and State law; its immediate concerns are serving the bests interests of its patient, who is also a child, while honoring Mrs. Anderson's rights as a parent/representative of the minor patient. In this…
What Should Be Said To Mrs. Anderson About Her Access To Records, Including Laws Regulating Access To And Disclosure Of Medical Records/Information Of A Minor Receiving Reproductive Care/Treatment.
Mrs. Anderson should be told that she is there solely in her capacity as a parent of a minor patient, that her capacity as a mid-level administrator is irrelevant to her instant rights, that any attempt to use her authority as a mid-level administrator to obtain her daughter's original records is an abuse of her authority, and that altering original medical records by unauthorized personnel (i.e., her), is illegal. She should also be told that her work as a mid-level administrator gives her greater insight into laws and hospital policies: the law and the patient's well-being supersede religious beliefs; that the record is what the record is and it cannot be changed by her; that access to the records is severely restricted by law and by hospital policy; that medical records are rarely released immediately upon request in any event; that medical records are not normally released to individuals in any event; rather they are released from facility to facility for purposes of treatment; that it is the provider's judgment that must determine whether it is in the patient's best interest to release the records; that in the instant case, neither the records nor a copy of the medical records will be released to her because, in the provider's judgment, release would not be in Sandra's best interests.
Though Sandra is a minor and Mrs. Anderson is her parent/representative, HIPAA recognizes that there may be circumstances in which medical records should not be released to the parent/representative of a minor (U.S. Department of Health and Human Services, 2012). In fact, even if the California law did not provide guidance, HIPAA provides that the hospital has discretion to provide or deny access, so long as that decision is made by a health care professional using his/her professional judgment (U.S. Department of Health and Human Services, 2012). As it happens, California Health and Safety Code §123115 (a)(2) provides that she is not entitled to inspect or obtain copies of the records when the health care provider determines in good faith that access would detrimentally affect the hospital's professional relationship with Sandra, or Sandra's physical safety or her psychological well-being (California State Legislature, 2003). In this case, release of Sandra's records to her mother would harm Sandra in all three aspects. Releasing the records to her mother could detrimentally affect the hospital's relationship with Sandra because she has advised us that she does not want her mother to
The issue of misplaced or lost patient files is also gotten rid of. These advantages aid in producing a marked rise in the health connected security of patients and the welfare of patients (Ayers, 2009). Furthermore, electronic medical records and patient care are identical in that such systems effortlessly permit restrictions to be placed upon end users' admission to specific information of the patient. This personal security feature is likewise significant to meeting a patient's confidentiality anxieties.
Figure 4 Electronic medical records and their advantages with patients (Slaughter, 2000).
The Benefits of access that is easy to each patient's comprehensive medical information, and the ability for physicians to rapidly take part in medical records and organize patient care. Even though every department at SMG utilizes the EM, it is particularly valuable in the Urgent Care Center when rapid admission to a patient's material can make all the change in medical…
Angst, C.M., Agarwal, R., Sambamurthy, V., & Kelley, K. (2010). Social contagion and information technology diffusion: The adoption of electronic medical records in U.S. hospitals. Management Science, 56(8), 1219-1241.
Ayers, D.J., Menachemi, N., Ramamonjiarivelo, Z., Matthews, M., & Brooks, R.G. (2009). Adoption of electronic medical records: The role of network effects. The Journal of Product and Brand Management, 18(2), 127-135.
Berner, E.S., Detmer, D.E., & Simborg, D. (2005). Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. Journal of the American Medical Informatics Association, 12(1), 3-7.
Brooks, R., & Grotz, C. (2010). Implementation of electronic medical records: How healthcare providers are managing the challenges of going digital. Journal of Business & Economics Research, 8(6), 73-84
Organizing Medical ecords:
One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced with the need of keeping and providing medical records. These individuals are usually responsible for providing copies of their medical records to health care specialists and consultants. In most cases, medical records are typically organized in various ways including:
This is a traditional patient record model that maintains reports depending on the source of documentation with each source of data containing a labeled section known as sectionalized record. In this format, all documents created by the nursing staff are located in record's nursing section, medical section for physician-generated documents, and radiology section for radiology reports (Green & Bowie, 2010, p. 89).
This is a more systematic method of documentation…
Green, M.A. & Bowie, M.J. (2010). Essentials of health information management: principles and practices (2nd ed.). New York: Cengage Learning.
Rajakumar, M. (n.d.). Numbering and Filing System. Retrieved November 19, 2011,
Weber, G.I. (n.d.). Achieving a Patient Unit Record Within Electronic Record Systems. Retrieved from University of Missouri -- Kansas City website: http://sce.umkc.edu/~leeyu/Mahi/medical-data9.pdf
Home Computerized Medical ecords
Computerized Medical ecords
One major advantage of computerizing medical records is that this method saves money and time for medical professionals. A traditional record system consists of files stored in a filing cabinet or other physical location. Files stored this way can easily become lost or displaced; the t time and resources to track down files that are missing can have a huge effect on the efficiency, effectiveness and revenue of the medical practice. Missing files can result in duplicate paperwork, lost time and productivity. For example, a medical office assistant that spends 20 hours a week searching for missing files, at an hourly rate of $15 costs the office over $14,000 a year in wasted time and money! Computerized medical records eliminate all these issues. With files kept in one database, they can be quickly located and retrieved. esulting in less rework and less…
Computerized medical records: Security, privacy, and confidentiality. (n.d.). Med League. Retrieved November 8, 2011, from www.medleague.com/blog/2010/10/13/computerized-medical-records-security-privacy-and-confidentiality
National-Academies.org | Newsroom. (n.d.). News. Retrieved November 8, 2011, from http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13269
Safety risks seen in computerized medical records . (n.d.). STL Today. Retrieved November 8, 2011, from http://www.stltoday.com/news/national/safety-risks-seen-in-computerized-medical-records/article_3de79c9a-da52-5c83-8236-fcad7e0b6991.html#ixzz1dDxPqTTI
The Benefits, and Potential Side Effects, of Sharing Medical Records Online - Knowledge @ Wharton. (n.d.). Knowledge @ Wharton. Retrieved November 9, 2011, from http://knowledge.wharton.upenn.edu/article.cfm?articleid=1846
computer-based vs. paper-based medical records, and discuss which are better. ecord-keeping is an important and vital part of any medical practice. Keeping medical records ensures the health and wellness of patients by tracking their overall care and health history. ecord-keeping is important for many purposes including legal information, health information and documentation, and keeping information that must be shared for professionals that are documented caregivers for patients. Thus, determining the best method for keeping records is vital to the patient and clinics success.
Keeping paper-based medical records has been the standard for some time. Paper records provide a wealth of information. Only recently has the computer been seen as an effective tool for keeping medical records. Computers are now considered a confidential and safe tool for keeping medical records. There are many advantages of computer-based medical records. Computers have the ability to store a lifetime of health data in a…
Lovis, C., Baud, R.H., & Planche, P. (2000). Power of expression in the electronic patient record: structured data or narrative text. Int J. Med Inf, 58-59, 101-110.
Shortliffe, E.H., & Perreault, L.E. (2001). Medical informatics: Computer applications in health care and biomedicine. 2nd ed. New York: Springer.
Tang, P.C., LaRosa, M.P., & Gorden, S.M. (1999). Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med inform Assoc, 6(3), 245-51.
Records of full medical operations are stored in primary storage facility, and are filed numerically in an attempt to realize efficiency. The filing system of an organization is usually numerical, and is based on terminal digits of the patient's HRN (Health Record Number). An up-to-date copy of the Paper-based medical records register should be kept in the file at all times. This may be the system used most of the time to locate medical records but it also provides a system to search when the power fail. Ideally, two-colored coded number of stickers are placed on the protruding right hand side back cover, of the medical record cover. These numbers normally match the last numbers on the HRN on the register. The digits that are colored, and in the case where they are misplaced, then it will show that the charts are misfiled. Ideally, file location can be determined from…
Consequently, in an attempt to ensure efficiency in chart filing system, it is vital for the management to retain and update the interim data collection tool at the health center and notify the information management officer of changes requiring central updating- HRN, given name and surname (Fordney & Follis, 2007).
Purpose of Paper Medical Record
The function of paper medical record is to provide guidelines for maintenance medical activities, its contents, security, and patients' confidentiality. However, the medical records available should always conform to the set requirements especially the rules and regulations guiding medical records. These laws are structured in federal and state constitutions. In addition, it provides a distinct definition
records are being replaced with electronic records in all fields. This is especially important in the medical field, where stores information is useful when a patient or doctor must access it in seconds. Computerized systems, however, have not achieved the same degree of utilization in the medical field as in other business fields, for instance, either in the Western world or elsewhere.[footnoteRef:1] However, as mentioned above, these systems can be vitally important. According to some, Electronic medical record systems lie at the center of any computerized health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerized medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries.[footnoteRef:2] Thus, though there are problems, these…
"With the federal government poised to spend $20 billion or more on healthcare IT as part of the economic-stimulus bill now before Congress, it's a good time to get to know these companies."[footnoteRef:3] [3: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from . ]
According to this, the striking thing is the concentration within the sectors. The study further states, "Meditech, a privately held Boston-area company, holds more than a quarter of the market; McKesson and Cerner, numbers 2 and 3 on the list, control another 27%. All told, the top six companies -- excluding in-house systems -- are responsible for three-quarters of the EHR installations in hospitals around America."[footnoteRef:4] [4: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from .]
The paper thus provides a ranging of the top ten vendors, which can be useful and which is as follows[footnoteRef:5]: [5: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from .]
HMS (healthcare management systems) and EMRs (electronic medical records) have been widely praised as significantly adding to patient safety and quality of care. They can permit healthcare institutions to keep more accurate databases on patients, all in one location, and can ensure that a patient’s full medical records are available, even if the patient is not responsive and the patient’s family is not available. Prior treatments, current and past medications, and patient allergies can all be easily accessed with a point and a click. But transitioning to such healthcare systems is not always without issues and often involves a significant investment of time and money.
First of all, from a staffing point of view, change management is needed to ensure that the transition is effective. One helpful way to view change of any kind within an organization is that of Lewin’s Change Management Model, which suggests that organizations must first…
Interoperability of Electronic Medical ecords
Electronic Health ecords (EHs) are patient-management tools that have been created in the health sector to help coordinate patient care. These tools or system focuses on capturing patient-generated health information from outside the clinical setting and incorporating it into the patient's medical history. Electronic health records were developed to help improve patient care through sharing patient information seamlessly. However, for EHs to have the ability to share patient information seamlessly, an interoperable health information technology environment should be established. This essentially means that an interoperable health IT environment is mandatory for electronic health records to be effective.
What is Interoperability?
Interoperability is a term used to refer to the level with which devices and systems can share data and interpret it (Healthcare Information and Management Systems Society, 2013). This means that two devices or systems are considered interoperable when they exchange data seamlessly and eventually…
Healthcare Information and Management Systems Society. (2013). What is Interoperability? Retrieved November 7, 2016, from http://www.himss.org/library/interoperability-standards/what-is-interoperability
Schiller, D. (2015, November 30). EHRs and Healthcare Interoperability: The Challenges, Complexities, Opportunities and Reality. Retrieved November 7, 2016, from http://www.healthcareitnews.com/blog/ehrs-healthcare-interoperability-challenges-complexities-opportunities-reality
Stroupe, M.P. (2011, May). What is EHR Interoperability and Why Should I Care? Retrieved November 7, 2016, from http://www.nethealth.com/wp-content/uploads/2013/11/What-is-EHR-Interoperability.pdf
Medical Coding Ethics
Ethical Concerns in Health Care Delivery: Focus on Medical Coding and Billing Practices
The objective of this study is to examine ethical concerns medical coding and billing in the physician office. Medical coding and billing has become very complex in light of health care reform. Recently, Christopher Gregory ayne, reported to be "dubbed the Rock Doc" was arrested on a dozen charges of Medicare fraud" when he was accused of fraudulently billing for "physical therapy procedures, such as massages and electrical stimulation, that were not necessary or in some instances had been provided at his prior medical practice in Miami." (eaver, 2013, p.1) It appears that where this doctor failed is billing for physical therapy when his staff was not properly accredited for providing these treatments.
Health Care Coding and Billing Changes
It was reported by Gunderman (2013) that October 1, 2014 is the deadline on implementing…
American Health Information Management Association Standards of Ethical Coding. (2008) AHIMA House of Delegates. "AHIMA Standards of Ethical Coding. Sept 2008. Retrieved from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166.hcsp?dDocName=bok2_001166
Know your ethical obligations regarding coding and documentation (2009) Association of Clinical Documentation Improvement Specialists, August 4, 2009 HCPro. Retrieved from: http://www.hcpro.com/HOM-236942-5728/know-your-ethical-obligations-regarding-coding-and-documentation
Weaver, J. (2013) Miami Beach's 'Rock Doc' busted on Medicare fraud charges. The Miami Herald. Retrieved from: http://www.miamiherald.com/2013/09/30/3660611/miami-beachs-rock-doc-busted-on.html#storylink=cpy
Sufficient documentation a major hurdle for ICD-10 (2013) APCs Insider. Retrieved from: http://www.hcpro.com/HIM-297687-859/Sufficient-documentation-a-major-hurdle-for-ICD10.html
' Since the paper is only used as 'back up' this means that the files are under lock and key, in a centralized location or in the department generating the data. They do not circulate throughout the facility, ensuring a greater chance of misplacement or security compromises. But even in this instance, errors can occur -- timely record-updating and writing times and dates next to new information when it is added to a patient's file is essential, to ensure that there is not a discrepancy between the patient's data kept in two different locations. In fact, one worker at one of the larger facilities expressed dissatisfaction with the paper back-up method: "Keeping everything together either electronically or on paper not both. Causes too much confusion," she or he wrote.
Unfortunately, in large and small facilities, even with security procedures such as password protections for digital data, safety concerns remain. Concerns…
How can eliminating abbreviations reduce errors?
In the medical profession, time is everything. To make documentation as expeditious as possible, a series of abbreviations have been accepted in records. This has been considered an acceptable practice as much as calling a registered nurse an "RN." The problems occur when people are unclear about the abbreviations mean or if a set of letters can have more than one meaning. For example, there is the abbreviation "CA" which means cancer and then "Ca" which is calcium. Another example is "a" which can mean both "artery" and "before" (Medical 2011-page 1). It is very easy to misread abbreviations when medical staff is in a hurry. Imagine the problem if a "q.w." which is take weekly was confused for a "q.v." which is take as one wishes. If the terms were written out rather than abbreviated, these potentially dangerous situations could be…
Berman, Jules. (2008). "Specified Life." Biomedical Informatics.
Greenall, Julie (2006). "Safe Medication Practices." Hospital News.
"Medical Abbreviations Glossary." (2011). JD-MD.
Barnsteiner JH. Medication reconciliation: transfer of medication information across settings -- keeping it free from error. Am J Nurs. 2005;05(3 Suppl):3-6.
This article evaluates the need for proper medication reconciliation across various nursing settings. This article is important as emphasis is placed on error free reconciliation which is very important for proper client service and treatment.
Bullough, Vern L. and Bonnie Bullough. The Emergence of Modern Nursing (2nd ed. 972)
This reference emphasized modern nursing and many of the practices and advances of nursing over the years. This is important as it provides a historical perspective of medical reconciliation. A historical perspective is needed to better understand improvements that will need to be made in the future.
D'Antonio, Patricia. American Nursing: A History of Knowledge, Authority, and the Meaning of Work (200), 272pp
This reference provides further evidence into the history of medical reconciliation and recommendations on improvements that should…
13. Rogers G, Alper E, Brunelle D, et al. Reconciling medications at admission: safe practice recommendations and implementation strategies. Jt Comm J Qual Saf. 2006;32:37-50
14. Snodgrass, Mary Ellen. Historical Encyclopedia of Nursing (2004), 354pp; from ancient times to the present
15. Sullivan C, Gleason KM, Rooney D, et al. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20(2):95-98
Health are -- Medical Retention Laws
Medical records retention requirements, whether Federal or State, are apparently aimed at maintaining records for a significant length of time after a patient's discharge. HIPAA does not impose a specific requirement for retention of a patient's medical records and leaves that task to State legislatures. alifornia meets and far exceeds Federal requirements in multiple requirements from multiple laws. Meanwhile, Nevada takes a far simpler tack while still adhering to Federal requirements.
HIPAA does not impose a length of time for which patients' medical records must be retained (U.S. Department of Health and Human Services, 2009); rather, that requirement is left to the states. However 45 .F.R. §164.530(j) does require that an entity governed by HIPAA must retain its "privacy policies/procedures, privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented" (U.S. Department of…
California's record retention laws are at least as strict as federal law, as required, and are often stricter. Beyond the HIPAA requirements binding covered entities, California has various strict retention requirements stemming from several laws. California's Code of Regulations §70751(c) (22 C.C.R. §70751(c) requires hospitals to keep patients' medical records for a minimum of 7 years after any patient's discharge and, if the patient is a minor, the records must also be retained for a minimum of 1 year after the minor has reached the age of 18 (California State Legislature, 2013). Also, the Welfare & Institutions Code §14124.1 states that the medical records of Medi-Cal patients must be kept by the provider for 3 years after the last date of service rendered under the Medi-Cal Program (California State Legislature, n.d.). In addition, the Health & Safety Code §1797.98e (b) states that providers reimbursed by the Emergency Medical Services Fund must keep patients' records for 3 years after the last reimbursed service was rendered (California State Legislature, n.d.). The Health & Safety Code under §11191 also requires that prescription books with issued prescription copies must be kept for 3 years after the last noted prescription was issued and that a provider who "prescribes, dispenses or administers a controlled substance classified in Schedule II" is required to make and keep a record of each such transaction for 3 years (California State Legislature, n.d.). Furthermore, under California's Code of Regulations §1300.67.8 (28 C.C.R. §1300.67.8), managed care plans governed by the Knox-Keene Act must also retain all "records, books, and papers of a plan" for 2 years, keeping the records available for inspection by the Commissioner of Corporations (California State Legislature, 2009, p. 54.5). California's Code of Regulations §39.5 also requires that in cases of Worker's Compensation, all qualified medical evaluators must retain patients' medical-legal reports for 5 years after the employees' evaluation (California State Legislature, 2013). Finally, regarding its state Occupational Safety and Health Administration (OSHA) program, California's Code of Regulations §3204(d) (8 C.C.R. §3204(d) requires that in cases of employees who were exposed to "toxic substances or harmful physical agents," providers must keep medical records for a minimum of the duration of employment plus thirty years (California State Legislature, 2013).
Nevada's laws regarding medical records retention
Describe briefly your topic of interest (15 possible points):
According to the United States Department of Health and Human Services (2013), medical reconciliation is "the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions." The process of medical reconciliation falls within the rubric of electronic medical records, which enable medical reconciliation. Medical reconciliation saves lives, improves the efficiency of hospital administration and of the healthcare team, and is simply necessary for providing quality of care.
#1 Database (or collection) (30 possible points):
Title of source:
"Electronic Health ecord (HE)"
Location of source (UL): http://www.ihs.gov/ehr/index.cfm?module=medication_reconciliation
Owner or publisher:
Indian Health Service
The Indian Health Service (2013) offers an overview of what medical reconciliation is, and how it applies to both individual and community health.…
"Electronic Health Record (EHR)," (2013). Indian Health Service. Retrieved online: http://www.ihs.gov/ehr/index.cfm?module=medication_reconciliation
"Medical Reconciliation," (2013). Greater Baltimore Medical Center. Retrieved online: http://www.gbmc.org/body.cfm?id=617
United States Department of Health and Human Services (2013). Electronic health record (EHR). Retrieved online:
It maintains these features for health information under the authority of "covered" units such as health care centre, plan or provider. Online storages such as Google Health and Microsoft Health Vault do not lie within the bounds of such kinds of units. This implies that their data is not as safe as they expect or assume them to be. The best approach to stay safe is to manage the electronic medical records in an online patient portal which works within the confines of the health care provider's information system. The private data which exists there will be covered by the terms of HIPAA. The level of access can be moderated to comply with the laws of the state. An instance of such a portal is the "PatientSite" created at the eth Israel Deacon Medical Center, oston. This kind of forum provides services such as secure messaging, registering appointments and updating…
Steinbrook, Robert. "Personally Controlled Online Health Data -- The next big thing in medical care" The New England Journal of Medicine, (2008): 1653-1656
"Electronic Medical Records - The pros and cons," healthworldnet.com. 1 March, 2009,
McCullagh, Declan, "Q&A: Electronic Medical Records and you," cbsnews.com, 19 May, 2009,
health information technology occupation and conduct a search of the Internet, consult professional
Thorough Job Details: Although there are not an abundance of qualifications that an individual must have to earn a position as a professional medical coder, there are several different avenues to pursue them. Candidates typically must have graduated high school or earned the equivalency of a high school diploma. Once they have completed this step, they can satisfy the general education requirements in a couple of different ways: either by earning an associate's degree or a postsecondary certification in health information technology or in a related field. Certificate programs typically last less than a year, whereas associate's degree programs are generally two years of full time study. The completion of these courses usually qualifies individuals to begin working within the field of medical records and health information technology as a medical coder. It is also permissible for…
Bureau of Labor Statistics (2014). Medical records and health information technicians. www.bls.gov. Retrieved from http://www.bls.gov/ooh/Healthcare/Medical-records-and-health-information-technicians.htm
Bureau of Labor Statistics. (2014). Medical and health services manager. www.bls.gov. Retrieved from http://www.bls.gov/ooh/management/medical-and-health-services-managers.htm
Medical and Billing Claims
I certainly do not agree with Tina's way of filling out an insurance claim. In fact, her method appears extremely suspect and potentially noxious to the company that both she and Tim are working for. The reason that I do not agree with Tina's way of filling out an insurance claim form is because she leaves far too much room for error. The fact that she would rather make an educated guess about the veracity of a claim based on unclear handwriting or terms she is ignorant about certainly does not bode well for her career -- or the degree of business that the company she is working for has. The billing and coding specialist position in the medical record field leaves little room for error.
There are a couple of rules or guidelines I would suggest Tina adhere to when attempting to fill out a…
Hobbes, T. (1651). Leviathan. www.Oregonstate.edu Retrieved from http://oregonstate.edu/instruct/phl302/texts/hobbes/leviathan-contents.html
Machiavelli, N. (2006). The Prince. Project Guttenberg. Retrieved from http://www.gutenberg.org/files/1232/1232-h/1232-h.htm
TOTAL EQUITY AND LIABIULITIES
(2) Discussion topic: Technology and Tools
Lower start-up costs. Fewer issues with maintenance of hardware. More resources including personnel and sophisticated procedures for security and backup of the patient information.
More ongoing expense over the long-term.
Subject to interruptions to the Internet, which restricts access to the EM data.
The clinical information may be stored along with data from other practices.
Enhanced patient safety with respect to drug allergies or interactions and proper dosage. Enhanced documentation with access to digital imaging and special testing. Better integration between the clinic and the business department.
Although somewhat remote, a vendor providing web-based EM…
EMR & HER: A forum for EMR, EHR implementation, selection, and meaningful use. Retrieved from http://www.emrandehr.com/2010/12/28/the-pros-and-cons-of-server-based-emr-systems/
Pollack, P.J.(2010). Medical Practice Trends. www.emrsimplyput.com
Evolution of Health Care Information Systems Physician's Office Operation
Filling in the hole of health care information technology will endorse safe, capable, patient-centered, and patient care that is fruitful in a timely way. In this essay, the theme is to look into two modern health
care organizations and then compare and contrast many characteristics that will involve the kind of evidence systems are using at the moment, investigate the transmission of information 20 years ago and how the substitute of data today. Furthermore, this essay will cover two major events and technology developments that have inclined present Health Care Informational Services practices.
Compare and Contrast Doctor's Workplace Operation
These day's doctor's office operation is familiarizing to the health care reform that was sanctioned in 2010 by the Obama organization. During sometime in October of 2013, the exchanges in health insurance was available on the market for customers on order to…
Burke, D., Wang, B., & Wan T.T.H. & Diana, M. (2009). Exploring Hospitals' Adoptionof IT. Journal of Medical Systems, 21(9), 349 -- 355.
Callen, J., & Braithwaite, J. & . (2008). Cultures in Hospitals and TheirInfluence on Attitudes to, and Satisfaction with, the Use of Clinical InformationSystems. Social Science and Medicine, 65(4), 635-639.
Finchman, R., & Kohli, R. & . (2011). Editorial Overview -- The role of IS inHealthcare. Information Systems Research, 22(3), 419-428.
Medical ID Theft and Securing EPHI
Medical Identity Theft
Medical information can be stolen by 1) the bad guys getting sick and using a victim's information to obtain services, 2) friends or relatives use another friend's or relative's information to obtain treatment, 3) when professionals, such as physicians, fabricate services that did not exist, 4) organized crime, and 5) innocent or not so innocent opportunists (Lafferty, 2007). ad guys that get sick can take a victim's insurance information to obtain services for treatment. Professionals can fabricate false claims to cover medical errors. Opportunists have access to patient data and the ability to steal, use, or sell that information.
Effective security requires clear direction from upper management (Whitman). Assigning security responsibilities and access controls with audit controls to organizational elements and individuals helps to place accountability on individuals. They must formulate or elaborate security policies and procedures based on the organizational…
HIPAA Security Series. (n.d.). Retrieved from HHS.gov: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/techsafeguards.pdf
Hoffman, S. & . (2007). SECURING THE HIPAA SECURITY RULE. Journal of Internet Law, 10(8), 1-16.
Lafferty, L. (2007). Medical Identity Theft: The Future Threat of Health Care Fraud is Now. Journal of Healthcare Compliance, 9(1), 11-20.
Whitman, M. & . (n.d.). Case B: Accessing and Mitigating the Risks to a Hypothetical Computer System, pages B1-B24 .
These examples highlight that technology is always a tool, a way of enhancing human judgment -- we must not mistake it as a replacement for good nursing practice.
After all, the use of a computer is no substitute for a medical education. Anyone who works in a hospital can see this -- the increased accessibility of information through the Internet also means that patients often come in, convinced that they are suffering from a serious illness, allergy, or condition, based more upon a diagnosis Googled on WebMD, rather than upon the fact that they saw a doctor! If a computer alone was required to diagnose, everyone would have a degree!
Don't get me wrong -- I use technology every day in my life, and thank my lucky stars, and my patient's lucky stars, that it is so ubiquitous. When health care providers wish to communicate, the use of cell phones…
In this case, that power dynamic was only exacerbated by the fact that the entire MSICU nursing team had never received training in management of the type of clinical issues presented and by the fact that they were excluded from any consultation in connection with a post-operative management plan.
Therefore, it is recommended that the institution immediately implement a policy of "see something, say something" according to which all members of healthcare teams are encouraged to speak up irrespective of power differentials. Furthermore, that protocol must include a statement of policy insulating any member of a healthcare team who does voice a legitimate concern in good faith from any retaliation or other negative response that could conceivably deter such diligence. Finally, the record of this case also indicates the immediate need for protocols requiring all members of the healthcare team to identify themselves to other members of the team, especially…
Bosk, Charles L. (2003). Forgive and Remember: Managing Medical Failure.
Gawande, Atul. (2008). Better: A Surgeon's Notes on Performance.
Groopman, Jerome. (2008). How Doctors Think.
Timmermans, Stefan. (2003). The Gold Standard: The Challenge of Evidence-Based
Medical Case Study
Florence (F) is a 43-year-old woman who is two days post-operative, following an appendectomy. She has a history of arthritis, and currently takes 10mg of prednisone daily. She is allergic to penicillin. She weighs 46 kg (101.5 lbs.) and is 168cm tall (5'6"). This puts her slightly underweight for her age and height, at least 18-25 pounds (Height and Weight Chart, 2010). While doing a route in dressing change, nurse notice a yellow discharge emanating from the wound.
Identify and discuss the importance of obtaining information during a nursing admission in relation to post- operative assessment. In modern healthcare, a nurse must first and foremost try to understand and utilize a systematic and synergistic model of data collection and assessment. Human beings are complex creatures, and the more data one has, the easier it will be to ensure that a proper diagnosis is made. A systematic assessment…
Height and Weight Chart. (2010). HealthCheck Systems. Retrieved from:
Prednisone and Other Corticosteroids: Balance the Risks and Benefits. (2011). The Mayo
Clinic. Retrieved from: http://www.mayoclinic.com/health/steroids/HQ01431
Nurses are required to make many immediate decisions in their assigned duties. Unfortunately, in recent years, patient care has often been compromised as a nursing shortage crisis has escalated to epic proportions. Increased patient loads have resulted in often hasty nursing decisions as responsibilities and hours worked have increased. Although precious time must be spread thin to accommodate higher numbers of patients, nurses must exercise their morals through consistency in ethical behaviors. According to Peggy Chinn (1), "Many ethical issues, such as end-of-life decision making, have increased in complexity. Other issues, such as advocacy and choice, have changed in certain respects but are more clearly centrally situated within nursing's ethical domain."
As a result, nurses are held accountable for a variety of decisions in nursing practice and in many instances, a patient's life depends on such decisions to survive. Gastmans (496) states that "Generally, the goal of nursing…
Chinn, P. (2001). Nursing and ethics: the maturing of a discipline. Advances in Nursing Science
Erlen, J. (2001). Moral distress: a persuasive problem. Orthopaedic Nursing 20(2): 76-80.
Erlen, J. (2001). The nursing shortage, patient care, and ethics. Orthopaedic Nursing 20(6):
Gastmans, C. (2002). A fundamental ethical approach to nursing: some proposals for ethics education. Nursing Ethics 9(5): 494-507.
Organizational change plan
Introducing electronic medical records (EM)
Along with expanding health coverage to more Americans, one of the goals of recent federal policy has been the widespread adoption of electronic medical records (EM) by healthcare providers across the nation. "The federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records" (Abelson, Creswell, & Palmer 2012). Having EMs can be used by providers to gain swift access to comprehensive information about a patient's health history. Some patients forget their history of diagnoses or the medications they are on; sometimes patients must be treated when they are in a mental or physical state where they cannot be forthcoming with information and their friends and families are not nearby. Also, there is the problem of patients attempting to obtain more pharmaceuticals or drugs which they should not be taking. "Electronic…
Abelson, Reed, Julie Creswell, & Griff Palmer. (2012). Medicare bills rise as records turn electronic. The New York Times. Retrieved:
Change theory by Kurt Lewin. (2012). Current Nursing. Retrieved:
Health Care Situation: Medical Error Due to Doctors' Bad Handwriting
Identify a health care news situation that affects a health care organization such as a hospital, clinic or insurance company.
I have identified the following health care news situation as the topic of my paper: "Poor Handwriting of Doctors and its implied risks for the Patient, Hospital and Medical Malpractice Insurance." Poor handwriting of physicians resulting in poor legibility of entries into patients' medical records carries very dramatic risks for all above-mentioned interest bearers. It can result in severe health danger for the patient and - in extreme situations - even cause a patient's death. Doctors' bad penmanship has long been seen a problem within organized medicine and the patient safety movement. Three American Medical Association (AMA) policies dating back to 1992, urge doctors to "improve the legibility of handwritten orders for medications" and review all orders for accuracy and…
Berwick, Donald M. & Winickoff, David E. (1996). The truth about doctors' handwriting: a prospective study. BMJ Vol. 313 (21-28 December 1996). 1657-1658. www.bmj.com/content/313/7072/1657.full, accessed 21 August 2011.
Bruner, Anne & Kasdan, Morton.L. Handwriting Errors: Harmful, Wasteful and Preventable.
1-4. www.kyma.org/uploads/file/.../Harmful_wasteful_and_preventable.pdfSimilar, accessed 22 August 2011.
Gallant, Al. (22 November 2009). For a secure electronic health record implementation, user authentication is key. 1-2). searchhealthit.techtarget.com/.../User-authentication-is-critical-for-pl.., accessed 24 August 2011.
Electronic Medical ecords (E-SIHI) in King Khalid University Hospital on Patient Safety
The objective of this study is to demonstrate the impact of e-SIHI (Electronic Medical ecords) on patients with regards to their security and safety. The King Khalid University Hospital has implemented the e-SIHI since May 2015 for all departments. Two weeks after the implementation, QMD (Quality Management Department) conducted an audit to measure a compliance for the system and ascertain whether the e-SIHI can improve health and safety of patients. However, the QMD found that there are many areas requiring improvement in the system. The paper discusses the methodology used to evaluate the system to ascertain whether e-SIHI is beneficial to the patient.
The research methodology reveals research design discussing the method of data collection, sample population, sample size, and project tool.
Study Design: The team audits the e-SIHI using a checklist to verify whether the…
AlAswad, A.M. (2015). Issues Concerning the Adoption and Usage of Electronic Medical Records in Ministry of Health Hospitals in Saudi Arabia. School of Health and Related Research (ScHARR) the University of Sheffield.
Bowman, S. (2013). Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspectives in Health Information Management, 10.
Jang, J., Yu, S. H., Kim, C., Moon, Y. et al. (2013). "The effects of an electronic medical record on the completeness of documentation in the anesthesia record, International journal of medical informatics, 82(8):702-707.
Kazley, A. S. & Ozcan, Y. A. (2009). Electronic medical record use and efficiency: A DEA and windows analysis of hospitals, Socio-economic planning sciences, 43(3): 209-216.
Provider Document Guidelines)
Provider Documentation Responsibilities
Summary of Key Concepts
Authentication of patient record entries
All entries in the medical record must contain the author's identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.
Abbreviations used in the patient record
All abbreviations use should be kept to an absolute minimum for effective and safe communication in patient care. Abbreviations should be avoided completely especially in drug prescriptions, operation lists and consent forms -- for example, the laterality of site of operation. Lists of approved abbreviations and their correct meaning should be established along with a list of 'Do not use' abbreviations to be followed by the healthcare professionals.
Legibility of patient record entries
The record must be legible to someone other than the writer. All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be…
Schneck Medical Center: The Baldrige Award
Schneck Medical Center: Overview
The Schneck Medical Center according to the National Institute of Standards and Technology -- NIST (2011) "is a 93-bed nonprofit hospital providing primary and specialized services to the residents of Jackson County, Ind., and surrounding communities." The facility as NIST (2011) further points out, offers a variety of primary care services including but not limited to cancer care, noninvasive cardiac care, and joint replacement.
Established in 1911, the facility was amongst four organizations selected by the President and the Commerce Secretary in 2011 to be awarded the Malcolm Baldrige Quality Award. This particular award in the words of NIST (2011) is "the nation's highest Presidential honor for performance excellence through innovation, improvement and visionary leadership." It is important to note that apart from the Baldrige Award, Schneck Medical Center has been a recipient of several other awards including the Outstanding…
Greene, A.H. (2012). HIPAA Compliance for Clinician Texting. Retrieved May 28, 2013, from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049460.hcsp?dDocName=bok1_049460
Hester, D.M. & Schonfeld, T., (Eds.). (2012). Guidance for Healthcare Ethics Committees. New York: Cambridge University Press.
Hernandez, S.R. & O'Connor, S.J. (2009). Strategic Human Resources Management in Health Services Organizations (3rd ed.). Clifton Park, NY: Cengage Learning.
Lyer, P.W., Levin, B.J. & Shea, M.A. (2006). Medical Legal Aspects of Medical Records. Tucson, AZ: Lawyers & Judges Publishing Company.
Electronic Certificates of Medical Necessity: A Proposal
Medical billing can now become a relatively painless process for the personal in a medical facility through the electronic filing of certificates of medical necessity (e-CMN). Manually filling out paperwork is very time consuming, and is not very cost effective. However, the technological advancements created in the area of medical billing are very efficient. While many offices now fax the CMN's, the incorporation of e-CMN's into the medical office and billing process, decreases overhead costs, reduces paperwork, and helps substantially with the on-going battle to comply with the ever-changing Medicare requirements. While each of the previous reasons is enticing enough to consider incorporating e-CMN's into the office routine, the increase of revenue is certainly a major benefit and is the direct result of the time reduction with the filing process.
Billy Tauzin, chairman of the U.S. House Committee on Energy and Commerce, clarified…
Bachenheimer, C. (2001, Aug. 1). Something out of nothing. Home Care Magazine. Retrieved April 13, 2004 at http://homecaremag.com/ar/medical_something_nothing/index.htm .
Business Wire. (2004, Feb. 13). American association for homecare and Trac Medical Solution agree on industry wide ecmn solution. ProQuest Document: 545984641 http://gateway.proquest.com/openurl-url_ver=Z39.882004&res_dat=xri:pqd&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&genre=article&rft_txri:pqd:did=000000545984641&svc_dat=xri:pqil:fmt
McClinton, D. (2001). E-CMN's. Home Care Magazine. Retrieved April 13, 2004, at http://homecaremag.com/ar/medical_ecmns/index.htm .
Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma
Today, the Department of Veterans Affairs (VA) operates the nation's largest healthcare system through the Veterans Health Administration (VHA), including 152 medical centers (VAMCs), 800 community-based outpatient clinics and numerous state-based domiciliaries and nursing home care units (About VA, 2016). As the second-largest cabinet agency in the federal government, the VA's budget exceeds the State Department, USAID, and the whole of the intelligence community combined) with more than $60 billion budgeted for VHA healthcare (Carter, 2016). One of the VHA's largest medical centers that provides tertiary healthcare services to eligible veteran patients is the Oklahoma City VA Medical Center (OKC VAMC) in Oklahoma City, Oklahoma. Like several other VAMCs, the OKC VAMC has recently been implicated in a system-wide scandal concerning inordinately lengthy patient waiting times and misdiagnoses which may have contributed to the deaths of some veteran patients and jeopardized…
About the Oklahoma City VA Medical Center. (2016). Oklahoma City VA Medical Center. Retrieved from http://www.oklahoma.va.gov/about/ .
About VA. (2016). Department of Veterans Affairs. Retrieved from http://www.va.gov / about_va/vahistory.asp.
Breen, K. J. & Plueckhahn, V. D. (2002). Ethics, law, and medical practice. St. Leonards, NSW: Allen & Unwin.
Carter, P. (2016). How to fix the VA. Slate. Retrieved from http://www.slate.com/blogs / the_works/2016/03/25/slate_s_infinite_scroll_implementation_explained.html.
Medical Death Investigative Systems
Past and Present Systems
Death investigation of some sort has existed in all countries for centuries, but not always performed by medical professionals (Committee, 2003 as qtd in Moldovan, 2008). The link between law and medicine traces back to the ancient Egyptian culture in 3000 .C. This was followed by the English coroner system in around the 12th century. The 194 Articles of Eyre first used the term "coroner" by the English until brought by the first colonists to the New World, America as basis for a legal investigative function. A medical examiner replaced the coroner system in 1890 then functioning in altimore. A medical examiner is a trained medical specialist in pathology. The field of death investigation became more and more sophisticated in cities and States, like New York. The Office of the Medical Examiner was established in 1918. Its main…
National Academy of Sciences (2003). Medico-legal death investigation system workshop. Committee for the Workshop on the Medico-legal Death Investigation
System. Institute of Medicine: National Academy of Sciences Press. Retrieved on October 12, 2010 from http://books.nap.edu/openbook.php?record_id=10792&page=12
Moldovan, E (2008). The medico-legal death investigator. ProQuest: ProQuest LLC.
Retrieved on October 12, 2010 from http://www.csa.com/discoveryguides/medicalegal/review.php
Civil War Freedmen: Freedmen's Bureau ecords In The Aftermath
In the years following the American Civil war, fought between 1961 and1965, many freedmen lost their homes, got separated from their families, and lost all claim to the little property they had. Although nearly four million slaves were freed, towns and cities in the region lay in ruins and the economy was destroyed. Faced with the challenge of restoring social order and providing assistance to the distressed freedmen, the U.S. government came up with the Freedmen's Bureau, also known as the Bureau of efugees, Freedmen and Abandoned Lands. Established in March 1965 by President Abraham Lincoln, the main aim of this Bureau was to provide relief effort to the former slaves from the south; and to facilitate the social reconstruction that would make the freedmen full citizens. The Bureau also helped them reunite with families, purchase land, establish schools, and even…
The Valley of the Shadow (1865-1870). Freedmen's Bureau Records: Race Relation, Family, Education. The Aftermath. Retrieved 9 April 2015 from http://vshadow.vcdh.virginia.edu/fbureau/bureau_topics_race.html
individuals seek medical aid everyday in order to conceive a child. "Generally, worldwide it is estimated that one in seven couples have problems conceiving, with the incidence similar in most countries independent of the level of the country's development" (National Institute fo Health and Clinical Excellence, 2010). Through new technology, conceiving a child is now possible for individuals who were never able to previously. One such method is through egg donation and bioengineering. This process is for a woman who is unable to contribute a viable egg in order to produce a zygote. Egg donation has become an increasingly popular method of conception. This method should be completely illegal for several reasons.
Egg donation companies supply these eggs through donors. Donors go through a rigorous screening process. This process can include everything from disclosing medical records, meetings with psychologists, medical testing, and signing an informed consent form. Once a donor…
ConceiveAbilities. (2010, December 12). Egg Donor Compensation. Retrieved December 12, 2010, from ConceiveAbilities: http://www.conceiveabilities.com/donor_pg_4a.htm
Egg Donation: Legal-Ethical Issues. (2010, October 13). Retrieved December 8, 2010, from Med India: http://www.medindia.net/patients/patientinfo/egg_donation_issues.htm
Kara N. Maxwell, I.N. (2008). The incidence of both serious and minor complications in young women undergoing oocyte donation. Fertility and Sterility, 2165-2171.
National Institute fo Health and Clinical Excellence . (2010, March 30). fERTILITY- INFORMATION FOR THE PUBLIC. Retrieved December 10, 2010, from NHS: http://www.nice.org.uk/guidance/index.jsp?action=download&o=29271
The theory has three factors:
Equity Theory -- Stated that a person compares their outcomes and inputs with others. Sarah has a meeting to discuss the salary of the whole entire organization. They realized that women were low paid in comparison to the men. Sarah started comparing herself with one of her colleagues saying that she worked harder than him and she has been there longer than him.
Satisfaction performance theory -- Porter and Lawler (1968a) state that it is not a motivational model that had dealt with the relationship between satisfaction and performance. Sometimes any reward that an employee may get is not related and how well he/she performs their job. Although this case does not tell us what type of reward Sarah was getting for her job we can see that her level of satisfaction she had when doing her job. She perceived that a…
Health Care continues to undergo fundamental change. Legislation such as the affordable care act has created a much higher percentage of insured citizens. Patent legislation is now allowing for much more competition for popular drugs. Generic drugs in particularly which are cheaper for consumers and much more profitable for producers are now eroding the market share of popular products. Even the use of cloud computing is changing the way care is administered within a facility. Even with these innovations, facilities still struggle with bloated cost structures, inefficient behavior, and lack of staffing. MGH is not different in this regard. It suffers from a large influx of patients with the inability to provide timely care. Below is a description of the issues combined with possible real world solutions.
Describe the current process and identify the specific areas that slow the process.
The current process has is inadequate primarily due to staffing…
1) Roukema, J.; Los, RK; Bleeker, SE; Van Ginneken, AM; Van Der Lei, J; Moll, HA (2006). "Paper vs. Computer: Feasibility of an Electronic Medical Record in General Pediatrics." Pediatrics 117 (1): 15-21
It would then become incumbent on the experienced coder to be able to read through the injuries and determine the accurate code to use. Another issue Kramer, Barancik, and Thode, Jr. (1990) found was that certain areas of the body lacked a code when injured to a very specific area of the body.
The training and education one needs to be a successful medical coder, and in particular a remote medical coder, is extensive. If we examine Figure 1 below, we can understand why this is so:
AAT (alpha-1 antitrypsin) deficiency 273.4
AAV (disease) (illness) (infection) - see Human immunodeficiency virus (disease) (illness) (infection)
Abactio - see Abortion, induced
Abactus venter - see Abortion, induced
Abasia (-astasia) 307.9
Abderhalden-Kaufmann-Lignac syndrome (cystinosis) 270.0
Abdomen, abdominal - see also condition
Kramer, Barancik, and Thode, Jr. (1990) found
Abduction contracture, hip or other joint -…
American Health Information Management Association (AHIMA). (2011). Quality healthcare through quality information. Retrieved from http://www.ahima.org/Default.aspx/ .
Kramer, Caroline F., Jerome I. Barancik, and Henry C. Thode, Jr. (1990). Improving the sensitivity and specificity of the abbreviated injury scale coding system. Public Health Reports, Vol. 105, No. 4, pp. 334-40.
Rodecker, Kristy. (2010). Medical billing and coding. Retrieved from http://www.medicalbillingandmedicalcoding.com/ .
Taylor, JM. (2008). [Emergency Department] Management. Experienced coders help ED create excellence. The Monthly Update On Emergency Department Management, Vol. 20, No. 11, pp. 123-5.
large number of changes in the healthcare industry, largely due to globalization and technological improvements. Much of the change has been the result of the cost of healthcare and its continual rise. For example, in 1990 the average cost of care per person was $2,800, in 2000 it was $4,700 and then in 2010 close to $8,000. One way to reduce these costs and improve efficiency is to allow healthcare professionals to spend more time with their patients rather than filling out redundant paperwork, to increase information accuracy, and to provide a way for medical professionals in Emergency Rooms or other health care facilities to have access to critical patient information. his can be accomplished through the use of Electronic Medical Record Systems, or ERM systems.
Diabetes is a group of metabolic diseases that surround the body's ability to produce and use sugars and efficiently process those sugars. Globally, there…
The conclusions reached seemed robust and showed that the use of EHRs, particularly in the primary care system improves both the process of care and outcomes. This suggests that organizations should immediately implement EHR systems so that decision support, patient care, timing of appointments and efficiency of recording of data and tracking medications and treatment options is actually far more efficient in both monetary and patient centered outcomes. Certainly, room for improvement exists, and as EHRs become more sophisticated, it stands to reason that efficiencies, outcomes and improvements in decision support will also become expected by stakeholders.
Herrin, J., et al. (2012). The Effectiveness of Implementing and Electronic Health Record on Diabetes Care and Outcomes. Health Services Research, 47(4), 1522-40. doi:10.1111/j.l475-6773-2011-01370.x
medical home concept and describe the principles (operational characteristics mentioned above) of the PC-MH as defined by these organizations. How does this concept differ from the gatekeeper concept of Managed Care Organizations?
According to the 'gatekeeper' philosophy of health management organizations (HMOs), physicians are intentionally given incentives to reduce access to care. This is based upon the assumption that patients will want to obtain as much care as they can receive and physicians will want to bestow that care to please patients and incur more revenue. HMOs encourage physicians to do the opposite and often financially reward physicians for cost reductions and limiting access of patients to specialists or heroic treatments. In the HMO model, physicians try to restrict access to specialists when they do not deem it necessary.
In contrast, the medical home concept is viewed as a partnership between "individual patients, and their personal physicians, and when appropriate,…
Case for change to the PC-MH Model (2011). American Dietetic Association.
Retrieved October 19, 2011 at http://www.eatright.org/HealthProfessionals/content.aspx?id=7059
Joint Principles of the Patient-Centered Medical Home. (2007). American Academy of Family
Physicians (AAFP). American Academy of Pediatrics (AAP). American College of Physicians (ACP). American Osteopathic Association (AOA)
Medical Administration Service for File
ationale in Support of Selection of Heart Transplant ecipient
Because time was of the essence in formulating this decision, this memorandum for the record sets forth the decision-making process and that was used to select the most appropriate candidate for a heart transplantation procedure. It was my responsibility as lead surgeon to select the most appropriate heart transplant recipient from a pool of three candidates, each of whom had suffered from several health-related issues that adversely affected their suitability for the transplant procedure. Therefore, in order to formulate as subjective an analysis as possible in a timely fashion, a utilitarian ethical analytical approach was used to identify the candidate that held the most promise of using the gift of additional life from the heart donor to its maximum advantage. The utilitarian ethical analysis showed that of the three potential heart transplant candidates, the 12-year-old…
Andre, C. & Velasquez, M. (1989, Winter). Calculating consequences: The utilitarian approach to ethics. Issues in Ethics, 2(1), 37.
Hollingsworth, J.A., Hall, E.H. & Trinkaus, R.J. (1991). Utilitarianism: An ethical framework for compensation decision making. Review of Business, 13(3), 17-19.
Rosen, F. (2003). Classical utilitarianism from Hume to Mill. London: Routledge.
According to A.J. Larner's book, "A Dictionary of Neurological signs," prosopagnosia is a neurological condition, "a form of visual agnosia characterized by an inability to recognize previously known human faces or equivalent stimuli (hence a retrograde defect) and to learn new ones (anterograde defect)" (Larner, 2010). Larner further distinguishes between two forms of prosopagnosia: apperceptive and associative agnosia. This "category-specific recognition disorder," as G, Neil Martin calls it in his "Human Neuropsychology" is often, but not always, associated with other forms of visual agnosia such as alexia or achromatopsia.
Prosopagnosia can be congenital or developmental, or a consequence of brain damage, following a stroke, a brain injury, or caused by a degenerative disease (Kinai, 2013) . There are two types of prosopagnosia: apperceptive prosopagnosia and associative prosopagnosia. This form of visual impairment has various degrees of manifestation, from mild to severe and can or cannot be associated with other…
Bowles, Devin C. McKone, Elinor. Dawel, Amy. Duchaine, Bradley. Palermo, Romina. Schmalzl, Laura. Rivolta. Davide. Wilson, Ellie. Yovel. Galit.
Cognitive Neuropsychology, "Diagnosing prosopagnosia: Effects of ageing, sex, and participant-stimulus ethnic match on the Cambridge Face Memory Test and Cambridge Face Perception Test." Available at: http://www.faceblind.org/social_perception/papers/Bowles%2009%20CN.pdf
Sperry, Roger Wolcott. Ed.Trevarthern, Colwyn B. 1990. Brain Circuits and Functions of the Mind: Essays in Honor of Roger Wolcott Sperry, Author. Cambridge University Press
Newman, Nancy J. Miller, Neil R. Biousse, Valerie. 2008. Walsh and Hoyt's Clinical Neuro-ophthalmology: The Essentials. Lippincott Williams & Wilkins
Federal Trade Commission ruled on charges of anti-trust leveled against the Wisconsin Chiropractic Association. The WCA and its executive director, Russell A. Leonard, had been charged with organizing a conspiracy among members of the WCA, which represent 90% of the chiropractors in Wisconsin, of conspiring to force health care providers to pay higher rates for chiropractic services than they had previously paid.
According to the proceeding records (FTC, 2003) and published statements by the FTC (FTC, 2000a), the plan began when the federal government as well as many insurance companies adopted new billing codes to cover chiropractic treatments. In addition, two other chiropractors, Michael T. erkley, D.C., and Mark A. Cassellius, D.C., settled with the FTC on similar charges (FTC, 2000a).
The final settlement included about 2,800 words of restrictions on the WCA and Leonard, some of them extending to the year 2020 (FTC, 2003).
The FTC alleged that the…
Brookings Institution. 2002. "The Effect of Antitrust Policy on Consumer Welfare: Assembling the Empirical Evidence." June. Accessed via the Internet 2/27/03. http://www.ftc.gov/be/seminardocs/antitrustpolicy-consumerwelfare.pdf
Federal Trade Commission (FTC). 2000. "Wisconsin Chiropractic Association and Its Director Agree to Settle FTC Charges of Price-Fixing." March 7. Accessed via the Internet 2/27/03. http://www.ftc.gov/opa/2000/03/wischiro.htm .
Federal Trade Commission (FTC). 2000. Docket No. C-3943 Decision and Order.May 18, 2000. Accessed via the Internet 2/27/03. http://www.ftc.gov/os/2000/05/wisconsin.do.htm
Federal Trade Commission (FTC). 2003. "HEARINGS ON7 HEALTH CARE and COMPETITION, LAW, AND POLICY." October 1. Accessed via the Internet 2/27/03. http://www.ftc.gov/ogc/healthcarehearings/031001ftctrans.pdf
Medical Affairs Department: Implementing Electronic Database Record Keeping
This project is very feasible as it is a standard updating of record keeping procedures from manual to electronic database -- which is common practice among most records departments today. There is nothing exceptional or impractical about this project and it can be accomplished with relatively little cost, little time devoted to the transition, and few risks.
Technical Feasibility: The project is technically feasible and depends only upon the assistance of the IT division and the training staff/support system to help in the going-online phase of the transition. The database technology is standard for the industry and will be easily obtained and implemented.
Economic Feasibility: The project is economically feasible with systems ranging from low-cost to higher-end or premium packages. A medium-range database system will be sufficient for this project and is within the budget of the Department and can…
Essay 2: In what collegiate extracurriculars did you engage? (400 characters)
As Vice President of Phi Kappa Sigma, I co-managed the annual $30k budget, participated in 100+ hours of community service, volunteered for the Rutgers Dance Marathon, raised funds for the Embrace the Kids Foundation, and organized the annual Phi-Esta fundraiser for the Eric Legrand’s Foundation with several other fraternities. I also volunteered for the Leukemia Lymphoma Society.
Essay 3: Did you work for compensation during college during the year or the summer? (300 Word limit)
Yes, every summer I worked full-time. During the summers of my undergraduate career, I worked at Selco Associates, a distribution and warehousing company. There I coordinated with management personnel to provide high quality customer service. I also managed apparel and footwear inventory for major companies and assisted in opening new accounts. This experience helped me to develop communication, organization, and problem-solving skills that I…
CPT codes in medical offices that employ Health Information Management professionals. Many current practices are using HIM professionals to help document patient visits and any treatments performed or offered to them. Having well trained HIM personnel can help the practice receive maximum reimbursement for the services that are performed there. This brief review will document the numerical system used for CPT codes that are detailed in billing literature as well as the appropriate methods for using them.
Coding professionals provide an invaluable service to physician practices and hospitals as they are truly the front line defense as far as ensuring reimbursements are near or even at maximum for their patients. The medical team works very hard for the patients they serve, and they should be reimbursed for it appropriately. Correct and appropriate medical codes will allow the office to recoup as much as possible from the services they provide.
Torrey, T. (2011) What Are CPT Codes? http://patients.about.com/od/costsconsumerism/a/cptcodes.htm . Last accessed January 18, 2011.
Schneck Medical Center
Provide a description of the company, its mission, and values
SMC (Schneck Medical Center) is a nonprofit healthcare organization that provides specialized and primary care services. The center was established in 1911 with a donation of five thousand dollars and a land from Mary Schneck (Jcr, 2007). It was established in memory of the founder's Husband to provide healthcare requirements to people of Jackson County. Initially, the center had a seventeen-bed capacity but it has now developed to ninety five-bed capacity. SMC celebrated its 100th centenary in 2011. This medical center is located in Jackson Country where it provides medical services to people of this area and the surrounding communities. Schneck Medical Center provides a full continuum of primary care services (Jcr, 2007). Particularly the medical center focuses on the health of women, noninvasive cardiac care, bariatric surgery, cancer care and joint replacement. Schneck Medical Center provides…
Biller, J. (2008). The interface of neurology & internal medicine. Philadelphia: Wolters Kluwer Health/Lippincott Wiliams & Wilkins.
Cribb, A. (2005). Health and the good society: Setting healthcare ethics in social context. Oxford: Clarendon Press.
Rahman, N., & de Feis, G.L. (2009). Strategic decision-making: models and methods in the face of complexity and time pressure. Journal Of General Management, 35(2), 43-59.
Johnson, K., Uecke, R., & Austin, R.(2006). The essentials of project management. New York: Harvard Business Press.
(Illicit Drugs or Nutritional Supplements?) It is more likely that some illegal gratification was sought and not received and that led to this action. Since this was also a case for medicines, one should also be careful of the problems that may come up.
What has been stated earlier is that it would be better to leave the enterprise to operations by South Africans and in that case, they will determine most of the staffing. It is not advisable clearly that many ozambicans be depended on for operations at least due to their ability. An example of this has just been stated.
2. Training and Development
When we are talking about a business and a possible collaboration with an existing business owner, they would have completed the training in an operating business. This would be helpful as the culture of South Africa and ozambique would be similar.…
Mozambique- people and society. Retrieved at http://www.oxfam.org.uk/coolplanet/kidsweb/world/mozambique/mozpeop.htm . Accessed 11 October, 2005
Mozambique-South Africa - Investment climate generally favorable, new report. 2 June 2004.
Retrieved at http://www.irinnews.org/report.asp?ReportID=41385 . Accessed 11 October, 2005
" (Harman, Flite, and ond, 2012) the key to the preservation of confidentiality is "making sure that only authorized individuals have access to that information. The process of controlling access -- limiting who can see what -- begins with authorizing users." (Harman, Flite, and ond, 2012) Employers are held accountable under the HIPAA Privacy and Security Rules for their employee's actions. The federal agency that holds responsibility for the development of information security guidelines is the National Institute of Standards and Technology (NIST). NIST further defines information security as "the preservation of data confidentiality, integrity, availability" stated to be commonly referred to as "the CIA triad." (Harman, Flite, and ond, 2012)
III. Risk Reduction Strategies
Strategies for addressing barriers and overcoming these barriers are inclusive of keeping clear communication at all organizational levels throughout the process and acknowledging the impact of the organization's culture as well as capitalizing on all…
Harman, LB, Flite, CA, and Bond, K. (2012) Electronic Health Records: Privacy, Confidentiality, and Security. State of the Art and Science. Virtual Mentor. Sept. 2012, Vol. 14 No. 9. Retrieved from: http://virtualmentor.ama-assn.org/2012/09/stas1-1209.html
Kopala, B. And Mitchell, ME (2011) Use of Digital health Records Raises Ethical Concerns. JONA's Healthcare Law, Ethics, and Regulation. Jul/Sep 2011. Lippincott's Nursing Center. Retrieved from: http://www.nursingcenter.com/lnc/cearticle?tid=1238212#P77 P85 P86 P87
Improving Customer Service on a Medical Surgical Nursing Unit
Quality Improvment Project-Customer service on the nursing unit
The hospital medical-surgical nursing unit is usually referred to as the "catch-all" department for different types of patients. This is because it includes renal patients, cancer patients, cardiac and surgical patient. It also includes other patients who do not particularly fall into any of these specialized units. The medical-surgical nursing unit is a conglomeration of all kinds of adults with all sorts of health problems and thus the nurses in this unit need to be dynamic, quick to respond and are almost on their toes at all times. Patients in the medical-surgical nursing unit are likely to develop changes in their condition quite rapidly and therefore they become more unstable even though they may have been admitted in a stable condition. This is because most patients in the medical-surgical nursing unit have unpredictable…
Amba-Rao, S.C. (1994). Human Resource Management Practices in India: An Exploratory Study. Indian Journal of Industrial Relations, 30(2), 190-202.
Dirks, K.T., & Ferrin, D.L. (2002). Trust in leadership: Meta-analytic findings and implications for research and practice. Journal of Applied Psychology, 87(1), 611-628.
Glickman, S.W., Baggett, K.A., Krubert, C.G., Peterson, E.D., & Schulman, K.A. (2007). Promoting quality: the health-care organization from a management perspective. International Journal for Quality in Health Care, 19(6), 341-348. doi: 10.1093/intqhc/mzm047
Judge, T.A., & Piccolo, R.F. (2004). Transformational and transactional leadership: A meta-analytic test of their relative validity. Journal of Applied Psychology, 89(1), 755-768.
All Medical Assistants
The importance of customer service in a tertiary healthcare setting
As you all know, the healthcare industry has been transformed in substantive ways as a result of the Patient Protection and Affordable Care Act and the growing need for timely recordation of services rendered in order to attain appropriate reimbursement of physician services and overall expense reimbursement for the medical facility. This memorandum explains how and why customer service is the one thing that sets their organization apart from their competitors.
Importance of Customer Service from Medical Assistants' Perspective
Please know that our organization appreciates your unwavering efforts to provide the best possible medical care to our valued patients. Medical assistants are on the forefront of the provision of this care, and we need your support to ensure that your services are compensated appropriately. This is in everyone's best interests because unplanned turnover can cost this organization…
They have a great deal of responsibility for selecting the images during the scan that provide the most comprehensive picture for diagnostic purposes, as well as recording their own preliminary findings.
Why did you apply to this health program?
I have worked three years as a 401K plan analyst. I enjoy making the complex financial services industry comprehensible to clients, but I am seeking a job that is more meaningful and hands-on that still makes use of detail-oriented personality. The field of medical sonography is fascinating and likely to be more and more important in the future because of its ability to quickly provide a portrait of a patient's state of well-being. Working in the field will allow me to be in close contact with patients and to give them meaningful comfort, advice, and care during diagnostic procedures.
Terrible oads Houston Medical Center
Unfortunately, not all is well within the context of the Houston Medical Center. esidents and workers alike are being plagued with poor quality roads that are creating a situation where many are at a disadvantage in their own everyday lives. Potholes and poor roads throughout the Houston Medical Center facility are creating many residents and faculty alike to have to put up with poorly constructed roads, and thus potential damage to their own vehicles when driving on roads within the region. It is ridiculous in an era where public funds are being spent across the country for the residents of the Houston Medical Center region to have to continuously put up with such horrible road conditions. This can essentially create a situation where there is damage undertaken by vehicles driving on the premises. Vehicles of all types are being damaged while driving in the region.…
Dwight D. Eisenhower Presidential Library. "The Interstate Highway System." 2006. Available at www.eisenhower .utexas.edu/highway.htm.
Kuemmel, D. (1994, April). Accident study validates benefits of preventive maintenance. American City & County, 109, 52.
Takle, E.S. (1990, August). Bridge and roadway frost: occurrence and prediction by use of an expert system. Journal of Applied Meteorology, 29, 727-734.
Schnormeir, Russell H. "Asphalt Analysis, Sulfur Mixes, and Seal Coats," Transportation Research Record #1096. Washington D.C.: Transportation Research Board -- National Research Council, 1986.
My education consists of a Bachelors degree in Radiological Science, I also maintain a high grade point average (gpa), and pride myself on the care given to my study and work history.
Although I already have a bachelors degree in the field of radiology, that is not enough. I wish to obtain a higher understanding of the subject matter, addition hands on experience, and the opportunity to use all the resources that will be afforded to me by continuing education to a higher level. I realize the need to continue in education if I want to work in the medical field working more extensively within the realm of radiology. Thank you in advance for the opportunity to express my desire in the field of radiology and what I hope to do upon being given the opportunity to continue at the graduate level.
ole of Biostatistics
Biostatistics plays an important role in the informing and guiding of public health policy and practices. The reason for this is simple: quantitative data goes a long way in indicating a clear and precise picture of the extent to which a phenomenon is affecting or impacting a population. Biostatistics can provide information and that very extent and underscore the importance of implementing a policy, of changing a policy's course/direction, of developing a new approach to dealing with public health, and/or of promoting new practices. Biostatistics provide a gathering of and interpretation of data that can then be used by policy makers as support for initiatives that would otherwise stall for lack of proof or evidence regarding why and how they will be effective at addressing a specific problem (Bertolote, Flieschmann, 2002).
The issue of translational research and whether or not it is being effectively used to create…
Analyzing Research Questions about Survival. (n.d.).
Bertolote, J., Flieschmann, A. (2002). A global perspective in the epidemiology of suicide. Suicidologi, 7(2): 6-8.
This is particularly the case in sub-Saharan Africa where clinicians have often come to rely on signs and symptoms alone to make diagnoses." (Nicoll, Walraven, Kigadye, Klokke, 1995)
The laboratory environment is critical to administering testing to determine population rates of HIV / AIDS throughout nations and perhaps continents where the lacking of resources facilitates a substandard environment for care. In the case of the African nation of Mozambique, which perhaps can be understood as a case indicative of the environmental assessment one would find throughout Africa and therefore, can be labelled to be a median statistical nation. A nation representing the median would indicate that half of the population nations that are categorized as resourced deficient, half would be above Mozambique in terms of resource allocation and half would fall below.
esearch into the quality of HIV / AIDS case-detection and case-reporting system in Mozambique was conducted by (Chilundo,…
Chappuis, F., Loutan, L., Simarro, P., Lejon, V., and Buscher, P. Options for Field Diagnosis of Human African Trypanosomiasis. Clinical Microbiology Reviews, January 2005, p. 133-146, Vol. 18, No.1
Chilundo, B., Sundeep S., Sundby J. The Quality of HIV / AIDS case-detection and case reporting systems in Mozambique. African Journal of AIDS Research 2004, 145-155. Copyright NISC Pty Ltd.
Clark. Blood Safety PPT. CDC, WHO
Loefler, I. Surgical wound infection in the Third World: the African experience. Journal of Medical Microbiology. Volume 47, 471-473. 1998. The Pathological Society of Great Britain and Ireland
The author also explains that the data stored in the system can be used to help public health officials identify medical issues facing the community as well as track various trends from the community and public health perspectives.
(How does this article relate to you as doctor?)
As a physician, I recognize that my time will be in very short supply. Therefore, any system or resource capable of saving time and increasing the efficiency of the healthcare services that I provide will be greatly appreciated. Similarly, patient safety, elimination of medical errors, and patient outcome are always paramount concerns for any physician. Therefore, I would welcome the opportunity to use EHR systems to the extent they address those issues positively. Moreover, as a physician, I am always interested in any approach that might be beneficial to human welfare and community and public health issues. According to the article,…