Records From Discharge-Permanent File

A. Describe the flow of records from discharge to permanent file. In a paper based environment all patients discharged papers is reviewed. Here are the steps involved with a paper base environment:
 Make sure there is no missing or incomplete documentation
 Codes and /procedures are correct
 Misspelled words are correct
 Place any missing papers or information in the patient file
The patient leaves the medical facility with each visit; the patient records are coded, billed, and filed. After, all patient information is completed it becomes permanent, after each visit.
With electronic records the doctor goes over the patient information, this includes any missing documentation or information. The major difference between paper
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 The patient leaves the medical facility.
 The staff scans all documentation into the computer.
 Patient records are ready for billing and sending to the proper insurance company.
 Scan medical records are faster and easier to locate.
Once again the patient records become permanent after each visit.
B. What type of computer systems dose the coders use? (i.e., encoder, GROUPER, etc.) The MT.Greenwood Eye Care Center uses Windows 7, 2.70 GH, and RAMS 4.0GB. The software package called Alta Point. Alta Point is a software package that is a customize software system for, this office needs. Alta Point offers versions tailored for the specific needs of each practice specialty, and offers extensibility PDA support. Alta Point comes with complete and added features:
 Windows have a variety of font sizes
 Doctor is able to get access to his files from a laptop or smart phone, on or off premises
 Doctor maintains current detailed clinical records, or notes for each patient
 Backups, are done nightly and weekly
 Medical codes and procedures, routinely updated by the vendor
 Integrated billing
 The office manager has the ability to schedule, an patient’s appointment via laptop on or off
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This approached is a tool designed to produce as many creative ideas as possible.
 Run Chart is to show trends in the variation, declines or improvement in a process over time. If the process is working or not. If the process needs updated or eliminated.
 A histogram is a vertical bar. It displays frequency on how often an error or something occurs in that department.
 Pareto Chart aids in identifying and rank types of problems. 80% problems come from 20% of the items. 80% of the defects are usually caused by 20% the cause, once identified.
 Flow chart, show how processes work visually and how the tasks in your project interrelate and that depends on each level in the organization.
 Control Charts purpose is to see what and where improvements need corrected. Differentiating between common cause variation and special cause variation basically, a way of determining whether the process is in control or corrective action needed.
Problem list put together with all factors that are contributing to the low productivity of the coders. Included in the list are:
 Education
 Experience
 Not enough staff

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