Mercy Gilbert Medical Center (MGMC) in Gilbert, Arizona is the focus facility of this interview summary. An interview was requested from a “Clinical Architect” from MGMC and the focus was on the newly implemented charting system and all that went along in that process. Some points of discussion were on software issues, security problems, interoperability dilemmas, and government regulations. Background Mercy Gilbert Medical Center opened in 2006 and houses 198 beds complete with an Emergency Room and a Level II Labor and Delivery. It also specializes in,”...a complete range of care back by the depth of expertise of heart, neurology, orthopedics, and surgery services ("Emergency Services," n.d., p. 1).…
CMS documentation also includes a rationale for ordering diagnostic and other ancillary services to be easily inferred. The rule also requires that the past and present diagnoses should be accessible to the treating or the consulting physician. CMs documentation must also identify health risk factors and determine the patient's progress, response to treatment, changes in treatment or revisions in diagnoses. All patient medical record entries must be eligible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.…
They can also share information with other providers for their patient. Cues integrated in the system alerts them to complete documentation that…
Assignment #1 Stakeholder: VP of Nursing System: Clinical Documentation System Over the past decade there have been many advances in software that provide advantages for clinical documentation. Clinical documentation is at the core of every healthcare encounter and current legislation dictates that it must be accurate and complete. If clinical documentation does not adequately and precisely reflect the treatment and outcome of each encounter, the actual quality of care that was delivered could be seen as irrelevant. With changes to the way healthcare is funded, clinical documentation, or the resultant data and information extracted from that documentation, is how providers and organizations are being measured and adjudicated. (Jamal, 2014) Benefits There are many benefits to be gained from the implementation of a new clinical documentation system but essentially…
Choosing the appropriate EMR (electronic medical record) vendor is essential to a successful transition from paper records to electronic medical records. Many factors must be weighed in this selection process. One method to help hospitals and practices make this complex decision is to complete a cost-benefit analysis. Entire books have been written on how to conduct cost-benefit analysis and an in-depth analysis goes well beyond the scope of this paper. Instead, this discussion will focus on how cost-benefit analysis can help to determine an appropriate EMR vendor.…
Concerns or issues that the PA feels the primary physician should know are written down. This allows the two to work together in order to provide the most effective care for the patient. During the examination the PA may learn the patient’s height and weight as well as any other basic information needed. They will also talk to the patient to find out more detailed information about the problem the patient is having, this information is then put into a clinical SOAP note. The note has four sections including subjective, objective, assessment/problem list, and plan3.…
The CPT or Current Procedural Terminology reference book includes a set of codes, descriptions, and guidelines determined by the American Medical Association, used to describe procedures performed by health care providers for billing purposes (Smiley, 2015). The tenth edition of the International Classification of Diseases (ICD-10) reference book provides a system of codes that classifies every disease and health finding identified by the provider, providing more than 68,000 different diagnosis codes (Smiley, 2015). The Healthcare Common Procedure Coding System (HCPCS), is a two-level coding system that identifies health care procedures, equipment, supplies, and to identify various items or services not included in the CPT medical code set (Center for Medicare & Medicaid Services, 2013). For example, if a patient come to the clinic only to receive a vaccine administered by a nurse, the vaccine administration would be the only reportable service (Smiley, 2015). For procedures such as vaccinations, an HCPCS code must be utilized for billing while an evaluation and management code would not be necessary (Smiley,…
Patients may have multiple duplicate charts throughout a healthcare organization due to simple typographical errors, name misspellings, inaccurate birthdates, language barriers, misinterpretations, misunderstandings, and communication errors between hospital staff, patients, outside caregivers, and family members. And remember, sometimes patients may be confused and unable to provide accurate information due to delirium, shock, dementia, psychosis, intoxication, or drug overdoses or they may even intentionally give inaccurate information for purposes of…
Most hospitals use charts to record patients' information, so they will need to write legibly and not use abbreviations unless everyone would understand them. After charting is finishing they will most likely have to enter it into an online program. Some of those programs could include Microsoft Excel, medical software, and the hospital's electronic mail…
Case Example of Nursing Terminology In managing a telehealth nursing team, I have been fortunate to take part in implementing our one-year new system. Our leadership team works closely with our implementations team, our clients and the nurses to create and maintain a standardized nursing system for the company. The job entails some computer programing in simple commands to manipulate client screens, setting up new client screens, creating client specific letters to import data and coordinating updates; so, the system is user friendly for nurses, the claims team and clients. Our system interacts with the claims team system and the client information system.…
Over the past decade, the term fraud has been brought to the forefront of coding and billing practices. Upcoding, unbundling or billing for services that are not documented are serious concerns for practices and payers. In a release from the Centers for Medicaid and Medicare Services, it was revealed that up to 30% of claims paid contained errors. Almost half of these were due to insufficient documentation (Prophet & Hammen, 1998). Ethics plays a big role in every aspect of health care, especially in medical coding and billing.…
My first though on this assignment was “ Who writes anymore? With all of the technology we have no one writes anymore,” I was wrong. I frequently find myself writing at work, at Intermountain Medical Center as a Patient Care Tech and as a Health Unit Coordinator. Often I am writing for myself, writing to my coworkers, other departments in the hospital and writing for as well as to my boss. Recently I noticed the longer I have been working at this job the more comfortable I am writing to my colleagues and my boss.…
Foundation of Knowledge model Discharge Summaries relate to Electronic Health Records Nursing informatics is a specialty involving knowledge and technology. According to McGonigle and Mastrian, The Foundation of Knowledge model is a “framework for examining the dynamic interrelationships among data, information, and knowledge used to meet the needs of health care delivery systems, organizations, patients and nurses” (2015). The Foundation of Knowledge model includes acquired knowledge, disseminated knowledge, processed knowledge and generated knowledge.…
Documentation comprises a vital aspect of nursing practice that not only chronicles the ongoing condition of a patient and his or her response to treatment, but simultaneously affirms that appropriate nursing interventions and care were provided. It serves as a record of the events that transpired, the medical approach that was elected, and the patient’s response to the care. Legally, if a task goes undocumented, it was not performed. Therefore, it is imperative that nurses understand and observe careful and meticulous documentation, as it is through such documentation that potentially devastating consequences and legal risks are mitigated.…
Formal standards in healthcare have derived from the need to develop a standardized system for informal applications within hospitals (Laureate Education, 2010). For example; hospital pharmacies, medical billing and clinical staff required an application to accomplish patient care in an ever growing field of information technology. Standards in healthcare were created to make processes work more efficiently (Hammond, Cimino, 2006) and comprise a set of rules and definitions that specify exactly what something is. In healthcare, specifically a hospital environment, a formal standard is useful because it permits two or more disassociated departments such as clinicians and pharmacies along with the billing department to work together in a cooperative way.…