...Electronic Documentation Nursing is a fast changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most recognizable changes in the medical field is the transformation from paper charting to electronic forms of documentation. This has led to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy. It was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with twenty five to fifty percent, which results in less time spent on patient care (Blair & Smith, 2012). This is alarming knowing that approximately a quarter to half of a nurse’s shift is done sitting in front of a computer documenting the day’s events. At Central Baptist Hospital I believe that more than half a day could be taken up by computer charting. From what I have experienced, a nurse may begin their shift with anywhere between four to six patients. These patients require a general...
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...Need for Teams Samantha Smith Need for Teams Background Goals and Objectives: The objectives for the first years of operation include are to include creating a medical call center that will be improved and have better customer service as well as exceeding the patients' expectations. Our agents will provide high-quality healthcare advice, products or assistance to residents of the area. We will serve our community’s needs. Forming a health care facility that fully capable to survive on its own cash flow within 10 months or less. To increase the number of call volume by 50% per year through improved customer service. To establish a creative website that includes online booking capability, as well complete information about the practice, hours, demographic information, health information and much more Mission The mission of the call center is to create the health and wellness of the local people by providing them with access to high-quality medical care for people young and old. The center is committed to providing these services exceed the expectations of each our patients, resulting in a successful and respectable business. Keys to Success Patients are the key to making the healthcare function. The call center main focus is on patient care. Educating the patients on the importance of preventative care helps prevent other diseases from taking over their bodies. Giving the patient their yearly checkup allows the doctor to discover if they educate patients. Figure out...
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...Electronic Medical Records and the Future of Medical Charting JoEllen McMullan Dr. Maria Lauer May 19, 2012 ABSTRACT Electronic Medical Records (EMR) is the transformation of documentation for nurses, physicians, pharmacists and all healthcare professionals involved in a patient’s care. It incorporates all orders, notes, prescriptions, therapies and the like of a particular patient’s progress along their path of treatment and recovery. EMR will transform the medical field in ways healthcare providers could not have imagined a decade ago. While there are positive and negative aspects of EMR, the ultimate result is one of accurate, precise and up to date patient records and communication between all disciplines in real time. INTRODUCTION Electronic Medical Records (EMR) is by far one of the biggest advances in medical charting in recent history. For years, documentation, charting, orders, and virtually any communication between healthcare professionals has been done in the format of “paper charting”. In other words, each professional would document in a patient chart, their particular contribution to that patient’s care on any given day. Not only is paper charting inefficient with regards to time, it also leaves tremendous openings for inaccuracies and errors. ELECTRONIC MEDICAL RECORDS I chose to research Electronic Medical Records (EMR) for multiple reasons. I previously held a position in a cardiology office where we transposed...
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...on a path of continued growth and success by improving their system of communications and documentations. A change that has in recent years become widespread in the health care field is the conversion of patient’s medical record into Electronic Medical Record (EMR). EMR provides an efficient system of recording patient’s medical information into a database that would be accessible to pertinent staff involved in the care of the patient. According to Scherger (2006), EMR implemented in larger medical offices and other medical facilities should not only mimic the already existing medical records; however, it should improve the maintenance and make patient’s information readily available (p. 49). When a patient request his or her record for transfer to another provider, the information is readily available in the EMR system decreasing the task of obtaining the data from paper records, in turn the provider can forward the patient’s information. Patient can receive his or her treatment without interruption. The change to EMR is beneficial to health care organizations as well as patients’ served for several reasons. The Institute of Medicine in 2000 estimated that more than 45,000 Americans die yearly because of medical errors that may are preventable with the use of the EMR (Richards, 2009). Handwritten charts and illegible penmanship can cause errors in administering incorrect medical treatment; however, the EMR can eliminate errors caused by this factor because the information...
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...An Ethical Analysis of Negligence In this paper, the author will describe the main differences among negligence, gross negligence, and malpractice in the medical field. In addition, the author will explain his opinion about this article and the facts described in it as well as the rationale used to form this opinion. Furthermore, the author will describe the importance of documentation in the medical field as well as how nurses should document when providing care while complying with legal and ethical requirements. Unintentional torts are the most common torts in the medical field. Torts are acts occurred without the tortfeasor intention to cause harm; however, some type of harm results from it. Torts are also actions committed unreasonably or disregarding the consequences, in legal terms this represents negligence (Judson & Harrison, 2010). According to Judson and Harrison (2010), negligence is an unintentional tort and a person is negligent when in similar circumstances he or she did not performed as expected from a reasonable person (Judson & Harrison, 2010). Defining gross negligence is a more complicated issue. According to Thornton (2006) the Texas Civil Practice and Remedies Code defines gross negligence as an act of omission that when viewed from the position of the actor at the time the omission occurred it shows a significant degree of risk and possible harm to others (Thornton, 2006). In addition, the actor is aware of the risks but proceeds disregarding the rights...
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...your record is in paper or electronic form, you have the right to your records. HIPPA contains specific incentives designed to accelerate the adoption of HER systems among providers. The HIPPA act contains 5 different sections. Tite 1, the health insurance reform. Title I protect health insurance coverage for individuals who lose or change jobs. Title 2 is known as...
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...extended, usually a minimum two years, sometimes longer (Cleverley & Cameron, 2007). Client Health and Rehabilitation Center a skilled nursing facility in Anywhere, NY has determined that a capital expenditure of an installation of electronic medical records (EMR) will help their facility compete with surrounding facilities. The cost will be roughly $50,000, and will consist of the hardware, labor, software, service, and education for facility staff. This paper will confer that attainment of electronic medical record hardware and software will facilitate organizational and management with facility goals based on the necessity of the facility to compete with other facilities in the area that are technically advanced. In the long run the facility will reap the rewards of the installation of this new technology. Management Goals Productivity The chief goals of the administration group at Client Health and Rehabilitation Center is that of productivity. With the organization becoming further advanced technologically owing to the use of the EMR system, responsibilities that consist of procuring doctors orders for updating, filing, and charting additional redundancies, and use many paper charts will not be necessary, thereby doing away this outdated responsibility. Acquiring information for chart audits to determine code status, new doctor orders, and accurateness of assessments will be completed with simplicity. The management...
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...improved documentations and communication. It is a big change of moving from paper-based nursing documentation to Electronic Medical Record (EMR) as required by the department of Health law that documentation of nursing intervention be done appropriately, and the care given be evaluated accordingly to improve the quality of care that nurses are rendered. This proposed change that is selected is designed for a long term care facility in Syosset, Long Island, with the vision to maintain excellence in care. The need in this health care facility for the change will be examined as well as the organizational and individual barriers to the change. Even though there are factors that might influence the change, there are also factors that will influence the organizational readiness for the change. The success of the changed will depend on the right theoretical model approach, and the right availability of internal and external resources. This new change will allow other providers to have access to the medical records without having to fax or mail them which may delay care. When a patient requires more intensive care such as cardiac distress that requires a transfer to a more skilled facility, the EMS transporter must wait for all the paper work to be done, including xeroxing the doctor’s orders, the labs, immunization, advance directive and more. While waiting for the paperwork to be done, the patient is prone to go in more distress. With the Electronic Medical Record,...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the...
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...organization for more than a year. For the purpose of this paper the capitol purchase discussed is one of the electronic medical record. The federal government wants all medical providers to have an Electronic medical record by the year 2014. To keep up with the growing changes in technology allotting for this purchase will greatly affect the hospital system in many ways and prove its return on investment (ROI). According to Health Revenue.com, “ The goals of the EMR are: * EMR will help to streamline the medical records process by bringing structure to how it is done * EMR will help to ensure medical records are more complete and correct * EMR will help to providers follow drug authorization more thoroughly to protect against errors and abuse * EMR will reduce transcription costs * Fewer charts will have to be pulled because physicians will have easier access to information, no matter where they are * EMR will improve clinical messaging and thus improve the work flow and care of patients * EMR will help make charge capture more accurate (2011)”. This paper will explore the management and organization goals, the impact on the economic environment, and justifiable expenses and relate them to the mission of the organization in regards to the purchase. This purchase is beneficial in many ways to the health care organization and will overtime pay for itself many times over. Electronic medical records are a move all health care agencies are moving towards...
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...Lesson Plan: Electronic Medical Charting NUR/588 May 19, 2014 Bianca Needham Professor Gail Wolf Identification of the educational need and rationale: The implementation of electronic documentation for medical records, medications, and nursing flow sheets has replaced the existing paper documentation and is currently the educational need with the highest priority for the Emergency Department at the University of Massachusetts Memorial Medical Center. In a continuous care operation, it is critical to document each patient’s condition and history of care, to ensure the patient receives the best available care. The medical record documents the care of the patient and can immediately be accessed, updated, and passed among the interdisciplinary team of caregivers. The Emergency Department is the initial passageway to the hospital for most patients. Electronic documentation is a patient’s health information including medications, allergies, past and present illnesses, and family history can be gathered upon their initial presentation and up-to-the minute revisions can be made by the healthcare team throughout their hospital stay. The Electronic Medical Record/Charting can be designed to hold collaborative information from all providers that are involved in the patients’ care. With each subsequent visit thereafter, the patient’s demographic, insurance, and health history database will automatically pre-fill the electronic template alleviating nurses of time restraints...
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...Communication through Electronic Medical Records Paper- based records have been around for many years, but with constant advancements in technology, much of information that once was recorded on paper, is now being recorded on the computer, in an attempt to eliminate paper-based medical records completely. Electronic medical records (EMR) are a replacement for the traditional paper charts. The main purpose of electronic medical records is documentation of the medical records containing the patient’s medical history, test results, care received, medications used, and any known allergies. This is very beneficial for many health care providers as well as their patients. Now doctors and nurses have the opportunity to evaluate and compare the patient’s medical history with each other; this helps them to accurately diagnosed the problem and determine the best plan of care for each patient. Benefits to Patient Utilizing EMRs decreases the amount of time that is spent on paperwork and reduces the likelihood of someone’s medical records getting lost, misplaced, or misfiled. This helps to improve both the quality and safety in caring for a patient. After all, there is no substitution for having accurate medical information about a patient along with immediate accessibility within the health care facility (Dr. Bill Crounse, 2005). All of the patients’ information is stored in a main computer server within the health care facility. Most health care organization’s computer system is...
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...Public healthcare services are administered by different regulatory authorities in the United Arab Emirates. The Ministry of Health, Health Authority-Abu Dhabi (HAAD), the Dubai Health Authority (DHA) and the Emirates Health Authority (EHA) are the main authorities. Ministry of Health and Emirates Health Authority The Ministry administers a number of federal healthcare laws, including (i) Federal Law No. 5 of 1984 (regulating the licensing and registration of physicians, pharmacists and other healthcare specialists within both public and private healthcare establishments); (ii) Federal Law No. 7 of 1975 and Federal Law No. 2 of 1996 (defining the specific requirements for establishment and licensing of public and private medical laboratories, clinics and hospitals in the UAE); and (iii) Federal Law No. 4 of 1983 (governing pharmaceutical professions and establishments and the import, manufacture and distribution of pharmaceutical products). The Ministry oversees the Northern Emirates healthcare system (the Northern Emirates include Ras Al Khaimah, Ajman, Umm al Quwain, Sharjah and Fujairah). Some of the Northern Emirates recently started establishing new healthcare institutions or reforming existing ones. Sharjah, for example, established the Sharjah Health Authority by Sharjah Amiri Decree No. 12 of 2010. The Ministry, however, still invests substantial efforts to improve the level of healthcare services in the Northern Emirates. The projects announced...
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...Data/Information/Knowledge/Wisdom Continuum Introduction Many organizations now have clinical documentation improvement programs (CDIs) designed to help an organization accurately reflect the quality of patient care, prove healthcare services, and make accurate reports of diagnosis and procedures (Cassano, 2014). A Clinical Documentation Specialist (CDS) is a registered nurse who manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, risk of mortality, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness (Cassano, 2014). Health Information Management (HIM) professionals advocate for a strong commitment to accurate and timely clinical documentation as hospital initiatives push forward with programs such as ICD-10-CM/PCS implementation, Accountable Care Organizations reimbursement models, Fraud and Abuse compliance programs, and implementation of electronic health records (EHRs) (AMIHA, 2010). HIM professionals also impact CDI programs by providing education regarding compliant documentation to physicians, something that is not taught in medical school. Successful CDI programs facilitate the accurate representation of a patient’s...
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