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Chapter 6

by: Kasi Greer
Kasi Greer
Medical Record Management
Laura Tharp, BSAS, CMA (AAMA)

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About this Document

Content of Patient Medical Record
Medical Record Management
Laura Tharp, BSAS, CMA (AAMA)
75 ?




Popular in Medical Record Management

Popular in Applied Mathematics

This 0 page Bundle was uploaded by Kasi Greer on Tuesday February 2, 2016. The Bundle belongs to 2616 at Youngstown State University taught by Laura Tharp, BSAS, CMA (AAMA) in Spring 2016. Since its upload, it has received 42 views. For similar materials see Medical Record Management in Applied Mathematics at Youngstown State University.


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Date Created: 02/02/16
YOUNGSTOWN STATE UNIVERSITY DEPARTMENT OF HEALTH PROFESSIONS COLLEGE OF HEALTH AND HUMAN SERVICES COURSE MEDICAL RECORDS MANAGEMENT COURSE CODE 22942 CATALOG MATEC 2612 SPRING 2016 Instructor Laura Tharp BSAS CMA AAMA Of ce Cushwa Hall Room 1084 Of ce Hours Directly before or after class in room and by appointment Of ce Phone 330 9413327 Class Site Cushwa Hall Room 1408 Class DayTime Mondays from 3pm to 450pm EMail latharDvsuedu Text Book 1 Green Michelle A and Mary J o Bowie Essentials of Health Information Management Delmar Learning 2005 2 Greene and Bowie Lab Manual for essentials of Health Information Management Delmar 2005 Notes Health Care Introduction Health Care 0 impacted by the cost 0 education 0 preventative care 0 Medical Necessity gt The quicker you get the patient in and out the more money hospitals make gt Review appropriate of charges gt Administration of treatment gt Preadmission testing as an outpatient to verify need for admission History of medicine Review table 11 page 3 0 Prehistoric Medicine belief of Gods 0 Ancient Medicine Egyptians Greeks 0 Medieval Medicine 0 Renaissance Medicine 13001600AD Modern Medicine 0 Edward Jenner discovered the small pox 0 Louis Pasteur amp Robert Koch established the germmicrobial theory 0 In 1845 Wilhelm Roentgen invented the Xrays Evolution of health care delivery in the US 0 1751 1St hospital in PA by Benjamin Franklin The Pennsylvania Hospital 0 1765 1st Medical School in PA by Surgeon John Morgan 0 1798 1st Marine Hospital Later the Navy 0 1847 American Medical Association elevate standard medical education 0 1887 Federal government lab in Staten Island for disease research 0 1906 Food amp Drug Act 0 19 0 1926 General Motors established group insurance plan 0 1929 1st Blue Cross hospital care 0 1935 Social Security Act 0 1939 1St Blue Shield Plan 0 1951 Joint Commission hospital survey meet its standards 0 1953 Department of Health Education amp welfare 0 1965 Medicare 65 or disability amp Medicaid less fortunate enacted as a part of Social Security Act 0 1974 Privacy Act HIPPA for Veterans 0 1977 HCFA now called CMS manage Medicare amp Medicaid 0 1985 COBRA allowed continued health benefits after job loss 0 1990 Patient Self Determination Act advance directives 0 1993 Vaccines for children programs 0 1996 HIPPA like the Privacy Act but for everyone 0 2001 CMS created to replace health care finance 0 2003 Medicare Prescription Drug Improvement amp Modernization Act can customize based of needs 0 2009 American Recovery amp reinvestment Act Continuum of Care page 12 Contains 3 levels Primary Care Secondary Care amp Tertiary Care Primary Care preventative and acute care 0 Early detection Minor Family planning Quickly in and out Seen by the family doctor Secondary Care Services are provided by medical specialist or hospital staff members 0 Physicians refer you specialist Tertiary Care specialized treatment 0 Burn care centers 0 CardiothoracicVascular surgery 0 Inpatient with AIDS 0 MRI s 0 Transplants I Surgeries I Scans 0 Traumas I Quaternary Care extension of Tertiary cares and is advanced levels of medical care 0 Experimental Medicine 0 Not used often 0 Very costly 0 Cancer experimental research Health Care Facility Ownership pg13 For Profit Not for Profit Privately owned Corporate owned Excess income distributed to shareholders and owners Excess income reinvested into the facility Ownership Hospitals are categorized according to 0 Government not for profit 25 of the hospitals in the US 0 Proprietary for profit 15 of the hospitals in the US 0 Voluntary not for profit 60 of the hospitals in the US E g Humanity of Mary Organizational Structure 0 Governing Board no pay and its members are professionals in the business community I Hospital operation I Organized management and control I Abides by hospital by law I Conducts meetings regularly I Hiring administration I Ensures competent staffing I Maintains professional standards I Assists employees in addressing physicains I Administration serves as liaison I Medical Staffs Physicians and licensed providers as allowed by laws 0 Active 0 Associate 0 Consulting 0 Courtesy O Honorary Hospital Committee Meetings 0 Agenda lists business to be discussed minutes record of actions taken amp decisions made I Date Place and time I Members present I Members absent I Guess present I Items discussed I Time meeting was adjourned I Location time and date of the next meeting I Sectary s name and signature Health Information Services I Department administration 0 Cancer registry credentialed tumor registrars computer programs I Coding and abstracting numeric amp alphabetical codes to diagnose I Abstracting is used to entering codes to make decisions recorded in charts 0 Image processing turning paper charts into electronic health records 0 Intranet like internet but only access to your hospitals Department Administration Incomplete Record Processing 0 Assembly and analysis of discharge patient records be organized of the patient 0 Universal Chart order discharge patient record is organized in the same as on the nurse oor Medical Transcription I Accurate amp timely transcription of dictated reports 0 Electronic signs are used 0 Digital signature 0 Smart cards barcode Record Circulation retrievel of records for the purpose of 0 Inpatient readmission 0 Scheduled and unscheduled outpatient clinic visits 0 Authorized quality management studies 0 Education and research Release of information processing 0 Written requests are reviewed 0 Included are request from patients physicians providers 0 3rd party payer social security diablitiy attorney Contract serVices 0 Improve quality While maintain costs 0 Housekeeping medical waste disposal emergency car speech pathology Licensure regulation and accreditation Chapter 6 Content of the Patient Record Inpatient Outpatient and Physician Office Introduction Health Care providers are responsible for maintain a record for each patient Who receives health care services Patient record is a valuable tool that documents care and treatment of the patient Every report in the patient record contain the Patient identification consists of the patient s name and some other piece of identifying information such as medical record number or date of birth Aliasthis is an assumed name during their encounter Addressograph machine Which imprints patient identification information on each report Facility identification including the name of the facility mailing address and the telephone number must also be included on each report in the record so that an individual or health care facility in receipt of copies of the record can contact the facility for clarification of record content Dating and Timing Patient Record Entries All patient record entries must be dated and timed Providers are responsible for documenting entries as soon as possivle after the care and treatment of a patient and predated and postdated entries are not allowed Hospital Inpatient recordadministrative data 0 Face sheet or admissiondischarge 0 Advance directives 0 Informed consent 0 Patient property form 0 Birth certificate copy 0 Death certificate copy Face sheet 0


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