...Abstract This paper will explain what the role of the patient’s history is in determining the correct evaluation and management code. I will list and explain the four elements of the patients’ history and I will give an example of what might be found in that element. The history section is the portion of the record that tells the physician what is wrong, and is based on the four elements. The patient is the one to supply the information for the history section. This section is where the provider can determine and assess the condition of the patient, by the history provided. The ancillary staffs personal are allowed to document this section of the medical record for the provider. They are permitted to document the chief complaint that the patient is complaining of. This section also contains any past history such as surgeries, child births if you a women. The family history is recorded here as well. This part of the history gives detail about the illness that other family members may have or have had. Cancer, heart dieses, diabetes just to name a few conditions that may be inherited from family members. There is also the social section of the history. This section speaks about your habits, do you drink and how much, do you spoke cigarettes and how many, are you a drug user and what type of drug are you using. Some physicians have special forms to be filled out that gives all the information that is required without the staff questioning you. If the history information...
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...Government Roles in Healthcare The government consists of federal, state, and local governments making this combination one of the largest payers of healthcare. The government has some important roles when it comes to the world of healthcare including the management of healthcare finances, the deliverance of healthcare, and the regulation of healthcare; these roles differ amongst the federal, state, and local governments. The federal government makes up the largest part of the government’s relationship with healthcare. The Fundamentals of US Health Care (2013) says that the federal government contributes three-quarters of healthcare spending to insurance programs such as Medicare, Medicaid, and CHIP. They also provide funding for mental health, medical education, community health centers, and public health programs. It also plays a part in delivering care to people. The federal government is responsible for delivering care to American Indians, the military, veterans, and those that are uninsured. With a large part of the world unable to afford health insurance this leaves the federal government responsible for that part. The Fundamentals of US Health Care (2013), states that the federal government also regulates the providers of healthcare programs by making sure there is no discrimination and regulating what drugs can be sold. With all the funding that the federal government provides, the care that it delivers to specific organizations, and the regulations that it provides...
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...Compassionate Healthcare is a national nonprofit organization dedicated to strengthening the relationship between patients and caregivers and preserving the human connection in healthcare. The Center reflects the vision of Ken Schwartz, a Boston healthcare attorney who died of lung cancer at the age of 40 and found that what mattered to him most as a patient were the simple acts of kindness from his caregivers, which he said made "the unbearable bearable." He founded the Schwartz Center in 1995 to ensure that all patients are treated with compassion. The Center is housed at Massachusetts General Hospital in Boston, where Ken received his care. Making Compassionate Care a Priority Through its National Consensus Project on Compassionate Healthcare, the Schwartz Center is bringing together patients, caregivers, policymakers, educators and researchers to better define compassionate care, develop best practices, and disseminate them to healthcare organizations across the U.S. The Center's goal is to ensure that compassionate care is a fundamental element in the design of health systems, the provision of care, the measurement of quality and outcomes, and the education of all healthcare professionals. Why Compassionate Care Matters Compassionate care is fundamental to the practice of all healthcare professions. It is characterized by effective communication and emotional support, mutual trust and respect, and involving patients and families in healthcare decisions....
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...Seminar 3 Short Paper – Healthcare Reform Philosophy of Ethics Healthcare Reform According to Teitbaum & Wilensky (2007), policies developed in different industries form an integral part of how individuals perform various activities aimed at assisting the society. Signing of Patient Protection and Affordable Act by the United States by President Barrack Obama led to a lot of changes in the health sector. The introduction of healthcare reform in the health sector act brought about many reforms that ensues affordable healthcare services to all regardless of financial status. The healthcare reform ensures every American citizen has a private or government insurance to take care of their hospital bills. In addition, more than 60% of citizens have their insurance covered by employers while Medicaid covers most low income earners, disabled people and people over the age of 65. Healthcare reform has introduced both virtue ethics and care ethics in the health sector through human resource capacity building and development and knowledge sharing as well as information management systems. The ethical issues that relate to health care requirements should ensure that clinicians and physicians have adequate training on how to handle ethical values in health problems. The health care practitioners are obligated to understand the ethical frameworks as well as moral theories related to influencing health care practices positively. Healthcare reform must follow a clear moral foundation...
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...Some believe health care to be a fundamental right while others consider it a privilege. Consider how you and your family utilize health care resources. Is access to health care a fundamental right that you exercise or a privilege earned? This topic strikes a sharp chord with me. Our family has insurance thankfully. Our family utilizes preventative medicine such as immunizations, dental cleanings and monitoring, and check-ups for my children at the pediatrician. My husband also has to have yearly physicals related to his job. We are very blessed to have access to healthcare in the ways that we do. We still have to pay our copays and expensive prescription deductibles, but am very happy with the insurance we have. I think healthcare is a fundamental right. Stating that healthcare is a privilege earned is absolutely ridiculous! My father has worked at a sawmill for at least 40 years. His boss chooses not to carry insurance and never has. My mother had insurance for a while when she worked at a local factory which laid off employees three years ago. Sine then, she has not been able to find steady employment. I can tell you that my family is one of the hardest working families there is. My father has COPD, has no insurance and cannot afford to pay for his much needed inhaled corticosteroids that he needs. My mother is a diabetic who takes insulin daily, What medications or doctor visits they partake in, is strictly on their own. How is this right? I understand that...
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...Jordan Four Functions of Management The essential responsibility to any business lies in the hands of their managers. How these managers provide the planning, organizing, leading and controlling, reflects on the success of reaching company goals and continuing to maintain competitive advantage. Maintaining these four functions requires managers to form groups of employees who will help to complete each plan successfully. According to (Bateman, & Snell, 2007), “In the business world today, the great executives not only adapt to changing conditions but also apply—fanatically, rigorously, consistently, and with discipline—the fundamental management principles. These fundamentals include the four traditional functions of management: planning, organizing, leading, and controlling. They remain as relevant as ever, and they still provide the fundamentals that are needed in start-ups as much as in established corporations. But their form has evolved.” Planning The very first function in the management process is known as planning. Basically, the determination of success or failure for any manager lies within each manager’s planning procedure. According to (Bateman, & Snell, 2007), “Planning is specifying the goals to be achieved and deciding in advance the appropriate actions needed to achieve those goals. Planning activities include analyzing current situations, anticipating the future, determining objectives, deciding in what types of activities the company will engage, choosing...
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...Hello Professor Kinney and Class, In the world of healthcare today, collaboration is often the key to excellent patient care and healing. “Working with others has always been a fundamental aspect of nursing” (National Council of State Boards of Nursing, 2005, p. 3). Successful collaboration can only be achieved through effective communication and interdisciplinary communication can be challenging for many. There are many strategies professional nurses can use to promote collaboration with other healthcare professionals, but the most important elements of successful communication, in my experience, are accurate exchange of information, listening, inquiry and maintaining mutual respect. In the ER and throughout the hospital leaving out even one seemingly insignificant sign or symptom can mean life or death for a patient and that piece of information can change a patient diagnosis completely changing the necessary care. According to Hood (2014), a professional collaboration is supported by shared respect to accomplish a mutual goal of better patient wellness. Using fundamental concepts like SBAR (situation, background, assessment, recommendation), hand-off, check-back and call-out are ways to make sure communication between professionals is complete, addressing all patient needs and concerns, concise, and respectful. Throughout this weeks Chamberlain lesson and this weeks reading assignments I found a connecting concept of showing mutual respect and working toward a common...
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...1984 Uncertainty of Illness Theory because healthcare organizations function on these theories guidance. Butts and Rich (2015) explain the implication of complexity science on the nursing profession as they describe it as the fundamental tenet of nursing. Complexity Science is the grand or general perspective that is a fundamental principle of nursing (Butts & Rich, 2015). The concepts that are applicable in complexity science include the healthcare facilities, organizational and systems analysis, and medical studies (Butts & Rich, 2015). These three concepts form the tenet of the current POI, which is about the health care access, medication, and conditions. This complex science is all about the sophisticated adaptive programs made up of individual components or “agents” that are interlinked in some ways but can act individualistically and at different times (Butts & Rich, 2015). The current POI is based on the concept of a healthcare facility that requires complex adaptive system. As a facility, health organization will act as both whole and agents; where the different units or departments such as environmental services, social work, nursing, the business office, and others (Butts & Rich, 2015). Each department can be divided into smaller components to...
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...Trends in the Workplace HRM 500 Instructor Name: Dr. LaQue Perkins, MPM, CIPM 10/26/2015 Human Resources role is to develop, plan and administer policies. There are several key functional areas which includes recruitment and selection, employee relations, compensation and benefits, and compliance. Recruitment and selection is designed to help an organization obtain applicants that are qualified to fill open positions. Recruitment identifies applicants knowledge, abilities, and skills to assist an organization to achieve goals and develop the workforce. It is very important to effectively select and recruit the right candidate to prevent turnover. The role of employee relations is to ensure positive relationships between staff and management, reduce conflict, improve morale, and maintain productivity. The goal is to ensure fair and consistent treatment of employees. The employee relations functional area must ensure the organization’s policies are being followed and resolved and problems and concerns are also addressed. The functional area of compensation and benefits in human resources set compensation standards, evaluate pay practices. Benefits refer to the non-monetary compensation an employee receive in addition to cash pay. The advantages of having a well thought out benefits packages are attract, and motivate employees; this creates job satisfaction, low absenteeism, and little turnover in your organization. Compliance in human resources ensures that an organization...
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...into consideration the whole person; body, mind and spirit as well as the environment in which they are cared for as an integral part of the healing process. In these hospitals, a holistic and family-centered care approach is crucial. There are 3 major elements that are basic to a healing hospital: a culture of fundamental love, an environment that fosters healing and aids in recovery and finally an integration of technology and an efficient work design to deliver safe and timely care. This paper will present the elements that comprise a healing hospital, the role that spirituality plays in the recovery of health as well as potential challenges that may impede progression towards the future implementation this model of care. Elements of a Healing Hospital A healing hospital is more than the physical building and the grounds that surround it. A healing hospital is a complete entity that is comprised of the patients, their families, and the entire healthcare team. The patient’s care encompasses all aspects of life; these include the physical, psychosocial, spiritual cultural and emotional health of the patient. The first element of a healing hospital is a culture of fundamental love, caring, respect and dignity for the patient and everyone in the hospital. “Healing experiences are truly meaningful connections...
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...belief of inter-professional practice, the roles and responsibilities of healthcare team members and the importance of inter professional communication in health care. Firstly, inter-professional practice has been discussed along with its significance for quality health outcomes. This is followed by the roles and responsibilities of a healthcare team member, which in this essay is a nurse. Lastly, the utilization of inter-professional communication has been described. Inter-professional practice in a healthcare setting refers to the relationship shared by the health professionals to get outcomes in the best interest of their patient as explained by my teacher. To provide a safe, caring and effective patient care the communication between health care members should also be effective and for this it is essential for them to understand communication concepts and techniques like, attending listening and probing (Berman, Kozier & Erb, 2012). The basic reason behind most of the medication errors, adverse reactions and near misses is due to inadequate communication between different health professionals be it oral or written, also the conclusion of many health care quality improvement investigations state that there is a lack of Inter-professional communication and hence suggest to improve it (Berman, Kozier & Erb, 2012). This collaboration between the professionals forms an integral part of the healthcare setting because the whole process of the treatment is based on communication...
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...area" (Ginsbury, Doherty, Ralston, & Senkeeto, 2008, p. 55). To make a system complete there has to be parts that bring it together. This paper will explore some of the components of a health care system, fundamental goals of a system and whether or not these components and goals interact with each other to form a whole. How medical treatment is arranged, financed and delivered are components of a healthcare system. Treatment is organized by the providers that offer the treatment and whether the providers are practicing in private practice, in small or large groups, or in corporate associations. Financing treatment includes any entity involved in payment of treatment services including the individual who requires the service or any type of insurance agency. Treatment delivery refers to the place treatment is provided, for example, rural or urban locations and inpatient or outpatient settings. Three fundamental objectives of a health care system include treating disease and disorders in individuals, promoting and maintaining the health of individuals and protecting individuals from economic devastation because of expensive medical bills (Mirmirani & Mirmirani, 2005, p. 58). Multiple systems are available to help individuals depending on what type of healthcare services are needed. Today's health care system is complex and multifaceted due to...
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...32400_CH17_Pass1.qxd 10/5/08 3:17 PM Page 413 Chapter 17 FUNDAMENTALS OF HEALTHCARE BENEFITS FROM THE EMPLOYER PLAN SPONSOR’S PERSPECTIVE CRAIG STERN PART 1 FUNDAMENTALS OF HEALTHC ARE BENEFITS FROM THE EMPLOYER PLAN SPONSOR’S PERSPECTIVE INTRODUCTION Healthcare benefits are designed to meet the needs of beneficiaries. Benefits must rest on the foundation of the organization’s needs and expectations. As such, a benefit is not defined until there are analyses of demographics, utilization, and the current and future requirements of the beneficiary population. Then the healthcare resources, costs and financial projections are analyzed to determine the infrastructure that will be required to deliver the benefits. This chapter focuses on the elements of healthcare benefits. WHAT IS THE NEED FOR HEALTH INSURANCE? Individuals at different age levels must ascertain their need for healthcare services. The uncertainty of one’s health and the expense of requiring hospitalization, physician care, or other health resources lead many to consider purchasing health insurance. As an economic and cultural decision, some purchase monthly benefits, while others choose only catastrophic care for unintended problems requiring hospitalization. 413 32400_CH17_Pass1.qxd 10/5/08 3:17 PM Page 414 414 Chapter 17 Fundamentals of Healthcare Benefits WHAT ARE THE TYPES OF HEALTH INSURANCE? Individuals (beneficiaries) may receive health insurance protection...
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...Therapeutic communication in its fundamental concept is providing a best treatment for patient based on patient-centre service. On the video case scenario, it is known that the woman is experiencing cerebrovascular attack. CVA or popularly known as stroke, needs a complex care as it involves plenty of communication barriers between patient and healthcare professionals, such as weakness, numbness, vision, and particularly, speech abnormalities (Grear & Bushnell, 2013). As stroke involves difficult communication, healthcare professionals need advanced skills of communication. For the purpose of the essay requirement, I will review how healthcare professional is conducting session with a patient from the therapeutic communication perspective. A patient is recently assigned to a hospital through emergency department. When paramedic team performs clinical handover to a nurse, he describes that the patient is 35 years old, 28 weeks pregnant and has history of hypertension. The nurse learns that she has difficulty in communication and gives a simple guideline. This is where the essence of therapeutic communication plays a great role. Anytime she shakes her head means affirmation and nodding means negation. Afterward, the nurse describes that there will be some other healthcare professionals visiting her. The first healthcare worker coming in after nurse is the radiographer. His intention is to inform and ask a consensual agreement of CT scan to the patient’s brain. The scanning procedure...
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... 2 Introduction Thousands of deaths are caused and could have been prevented if patient safety measures would have been taken. It is very important improve patient safety compliance to prevent things like surgeries being done on the wrong site, medication errors, health care acquired infections, falls, and diagnostic errors. Patient safety not only takes place in the hospital, doctors office, and rehab/nursing home facilities, but it also takes place in the home care setting. The Speak Up home care brochure is geared to inform that patient on what to speak up about in the home care setting and if the patient speaks up and the nurse of healthcare worker complies, more errors can be prevented. The home care brochure really gives that patient many options of questions to ask the nurse or healthcare working during their home care. It empowers that patient and hopefully helps them know what they are entitled to as a patient as far as home care, questions they should ask if they are concerned and for information purposes, and I hopefully helps the patient to not be not be afraid to ask question and to participate more in their care, which in turn will improve health care as a whole. Summary of Article The questions on this brochure range from checking credentials of the nurse or health care worker to asking the nurse or health care worker to explain each and every procedure they are performing and what medication they are giving. This brochure...
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