Medical record

For my experiential learning experiences I had the pleasure of visiting both the Ahtanum Ridge Clinic and the Yakima Valley Regional Hospital medical records. Before visiting these facilities I constructed questions beforehand to ensure I would not only have a valuable experience, but be able to compare facilities as well. These questions were; 1. What is something about the system you deal with that you know but not many other people you come in contact with know? 2. How has the change between…

Columba C. Millan is the Director of Medical Records at Broadway by the Sea, which is a skilled nursing facility. She immigrated to the United States from the Philippines in 1983. She studied in the Philippines and got a bachelor of science in professional agricultural engineer and then had to take the license exam when she came to the U.S. Even though Columba does not have a degree that pertains to health care, she does have about forty years of experience that has allowed her to grow within…

Technology has been advancing tremendously fast, so fast that we no longer use filing cabinets. The business aspect of keeping records on file has change because most office or clinic save everything on their computer or hard drive. Personally, we should scan patient information into the computer and also keep the actual paper. Why? Well in my homeland security class we learned about electronic magnetic pulse also known as a bomb that other countries have ready to launch into America whenever…

A yearly open enrollment is the only time these plans will be allowed to be purchased. This will eliminate individuals waiting until they are sick and facing medical bills. There are exceptions to this open enrollment term such as having a life changing event, loosing other coverage, getting married or having a baby. The next stage in the Affordable Care Act is to help care providers change their incentives…

forgotten when paper charting. Care givers are able to look back through the history of a patient’s chart which can show them a history of their progress during their stay. Depending on the system, users can sometimes look far back into a patient’s medical history. With optimal systems, charting can be quick and efficient allowing the care giver to spend more time with the patient. It can also give the nurse information needed for important teaching measures. Electronic charting comes with…

important. Therefore it is vitally important to complete a thorough pre-screening of each potential subject. In order to do this the following should be done; Request the Medical Records of the potential subject and make sure they are RECEIVED and reviewed PRIOR to Visit 1. Why is this so important? Having the Medical Records in advance is proactive and could prevent Protocol Deviations. The Inclusion/Exclusion of any protocol is not only there for collecting the data we need for the study,…

Patient encounter is group into three subcategories which are a patient specific, aggregate, and comparative. In addition, the patient specific date type usually consist of the medical history such as physician’s orders, consents, authorization, billing, and insurance eligibility. Also, the other main component of this data type is general operations. Next, externally comparative data come by internal and external data to assist organizations in evaluating their performance. The other main…

There are several problems with the current healthcare industry standards for information technology that need to be addressed. Issues such as the lack of electronic health record (EHR) interoperability and user security disrupt meaningful progression which significantly reduces the quality of healthcare. If we don’t figure out smart solutions the industry as a whole will be worse for it and a lot of providers will lose funding as a consequence. One of the main reasons that healthcare providers…

standards for medical personnel. Fourth, I will talk about rules regarding Quality Assessment and Performance Improvement within hospitals.…

Medical Identity Theft Out of all the places we should feel our identities to be most secure, the individualized, private rooms where we discuss our latest health concerns should be one of them. Unfortunately for some, that is not always the case. Although identity theft is more popularly known as the act of an individual taking one’s personal information for financial gain, it can also occur within the healthcare field (American Optometric Association). Not only do individuals fall victim to…