Sign Iowa Banking Medical History Now

Industry sign banking iowa medical history now

this presentation is about clinical documentation at the start we have to define what is the record so let's define medical record it's a file containing group of documents and or forms that containing all patient medical information for each separate visit to a health care institute there is another simple definition which is a chronological means arranged written account of the patient's examination and treatment that include the patient's medical history complaints the physician's physical findings the results of diagnostic tests and procedures medication and therabiotic procedures so it's a file containing all evidence of patient care it's a document it's a form it's containing all information we need about the patient himself so what's the importance of the medicare record meaning what kind of information we can take from the medical record meaning what's the uses of the medicare record what's the medicare record tells us we can find in the medicare record past history and the present condition of the patient the medical record is con considered as a communication tool among health care providers it's a very rich source of legal documentation we can take a lot of things related to legal issues from the medical record we can find inside the medical record patient and staff education it's an evidence and prove that the health care staff doing their job regarding education quality control and research we can take a lot of information helping us in establishing kpis indicators and for researchers use documentation for billing and coding this is regarding the the paying and the cost of the services especially if we are dealing with the companies related to insurance or insurance companies so again what's the importance of the medicare record it's a rich source of information of we can take general information from the medical records like name addresses ages nationalities and so on contact information any patient we can go through the medical record because you know that the first page of the medical record it should containing all the relevant information with the contact number with the ferris ticket with a photo of the id card of the patient itself it can tell us about occupations it can tell us about medical history of the patient current complaints healthy care needed all health care needs treatment plan or services provided to the patient radiology and laboratory results and response to the care if the patient is improved or not shifted or not transferred or not and so on so all of this we can know it from medical record again it's a legal source as we said before a rich legal source for information so what's the legal guidelines for the patient record it support a male brexit claim we can know who did something wrong from the medical record and what was the wrong issue again it's support as a defense for the malpractice claim if someone have a claim against the hostile or against a healthy care worker we can get the evidence of uh innocent he's innocent that he did not do the wrong thing again from the medical record it's a backup for financial records documentation everything is documented inside the medical record medical care evaluation and instructions done by by any health care giver we can find it inside the medical record and patient complain also it's a source of legal information inside the medicare record a very important question and we have to clarify it to all of ourselves that who have the authority to write in a medical record anyone in the health care institute can document or can write or can put his notes inside the medicare record the answer is no it's restricted only to a group of health care giver that have a direct contact with the patient we will give an example for them of course doctors doctors can write down in the medical record nurses and some borah medical and the medical health caregivers physicians dentists nurses patient educators other medical and borough medical staff for example that respiratory therapist those people have the right to document inside the medical record or have the authority others not for example we did not mention here that that for example the hospital director he have no rights to write inside the medical record in almost all facilities we have experienced well so those are the most important health care giver have the authority to write inside the medicare record okay what are the most important documentation instructions if you want your entry inside the medicare record to become complete you have to follow some instructions some of them are the following health caregiver shall be responsible for the completion of the health care record for his patients regarding to his forms for example physician he they have to finish the physician forms nurses they have to finish their nurses forms and so on so the healthy caregiver is responsible for his entry medical director have the ultimate responsibility for evaluation of patient health records be repaired by physicians so the ultimate response is over the medical director he have to follow up he have to give instruction he have to make sure that the physicians are trained for the correct patient medical record the entries the same foreigners is the same for health care education a health care educator so every head of department is responsible for his people medical director for physicians nurse director for nurses and so on again reviewers staff in the medical record department should review all coming records from the department on a daily basis when the medicare record is finished inside the world they will push it to the medical record department we have coders people named sorry named reviewers the reviewers in the medical record should review the medical record on daily basis and any defects they have to send it to the concerned staff health care record committee medical record committee shall critically assess the quality authentic record to ensure the medical staff compliance established standards we have two types of medicare record review open and closed and we will discuss it in the uh a near slide so here again we have to have a committee this committee is responsible for reviewing the medical record and finding any defects and reported to the concerned people so again all entries and the health care record must be clear legal to be eligible to be eligible and contain identification data or information including at least patient full name health record number required demographic by your facility so any form inside the medical record we have to document the demographic specially the full name three names or four names according to your hostile policy and the medical record number then every single entry should be legal it should be eligible and clear we can read it it's very clear because we saw some physicians they write something it's not legible it's not clear again all entries should be in blue or black and healthy record so you don't have authority to use the red band only blue and black and after you finished your entry you have to put your name signature date and time with the stamp if you do all of this if you make sure that you're four you bought the demographics on the form and you make your entry with a blue or black very eligible very clear sign stamp daytime it's considered as a clear or correct entry in the medical record again never delegate the authority of your stamp to anybody do not it is or cross out or use that load or liquids for any mistake so what i will do if i did any mistake in my entry you have to put a thin line of over the wrong word and about the word error then correct it then you have to put your name date time and signature with the stem that i made an error in the entry here and i corrected it you don't have the right to erase or but across or using the flarewood for it again you have to commit with the approved list of abbreviation and never use the prohibited abbreviation because it's the medical record is a way of communication between the health caregivers this is an example you have to make here a thin line over the world but error and correct it then write your name date time with the stem so what's the patient's rights regarding to medical record before telling you what's the patient rights regarding to his medical record and information inside the medical record there is two very very important notes note number one medical recorder itself is a property to the healthy care facility it's belonging to us in the hospital or in the phc it's ours as a medicare record but the information and data inside the medical record it's a property to the patient so you cannot disclose any of the data or information inside the medical record to anyone unless you have a permission from the patient but the medical record itself the form is inside it it's the property of the healthy care institute so what are the patients right number one the right to limit or request restriction on their phoi which is protected health information and its use and disclosure the right to confidential communication the right to inspect and obtain a copy patient can ask for a copy of his medical record or the information inside the medicare record the right to request an amendment to their medical record he can tell you do not allow anyone to go through my medical record and the right to know if there is any information disclosed to any facility or to anyone so this those are the patient rights regarding to his medical record so what's phi we told you that it's the protected health informations some important severity standards what we have discussed right now you can find it in the uh siberian standards regarding the medical record i think it's uh thunder read it to medicare record r 17 the chapter of medical record is 17 standard as i remember i will give you here only three to five standards so show what we have discussed right now standard number four medicare record that contains sufficient information to promote continuity and the coordination of care and documentation among care providers so the medical record contains sufficient information demographic history examination tests laboratory and radiological tests uh charge summary notes medication sheets uh assessment spar hand off technique everything should be there in and clear so it can make it's very easy communication between physician the physician nurse and nurse physician and nurse and so on medicare record standard number five is talking about the hostile has a complete and accurate medical record for every patient every single patient have a separate medical record all hostile and define a policy so we have to have a policy for initiation for uh medical record for every patient and who have the authority to make entries to end the medical record as we discussed it before all entries in the medical record must be eligible we discussed it before clinical staff authorized to make entries in the medical record receive formal training as we said before the medical director have to ensure that all the physician have training on how to uh make entry inside the medical record nursing supervisors and nursing department have to make sure about the training of their staff and so on the author of each entry must be identified and authenticated by official stem signature written initial or computer entry date time and stem with signature as we said before medical recorded completion is a requirement within 30 days if anyone have entered inside the medicare record and the reviewer or anyone looking at the medical record to find there is a defect inside the medicare record regarding the completeness we have to send this medical record to the consented staff and he have to finish it within 30 working days and it should be supervised by his supervisor uh and 5.6 thousand has a policy to do with the lincoln medical record if any any file is not complete what our policy to do it to deal with and those files are called delinquent not completed the most responsible physician is responsible for the completion we said before who have the responsibility for completion the medicare record the physician or the caregiver who have the ultimate responsibility his supervisor or director let's go for another standard which is a medical record saving a discharge summary is completed for the charge patient if you are discharging the patient you have to have a complete discharge summary what's the requirement here the reason for patient admission why we admit this patient patient diagnosis brief summary about hospitalization what kind of therapies consultation intervention results of any important diagnostic tests a list of medication used any surgery or procedure done the patient condition at discharge all medication to be taken by the patient after discharge at home and any special care for patient required after discharge like physiotherapy or some rehabilitation another medical record standard which is number 11 very important one we have to have a system that enable the medical record linkage we are talking now about voluminous medical records we have a very very big huge medical record some patients like chronic patients uh especially for example sickle cell anemia they can visit the hospital daily or two times a day uh bronchial adama they can't visit the hospital too much so you can find their files in the big and the huge file what we have to do it very simply you have to have volumes of this medical record someone we are dealing with which containing a summary for all the past visits all the all the visits for example this patient is uh bronchial abner he visited the hospital always the most important thing when he come he have to take uh bronchial bronchial dilators uh like salvation or whatever this patient have hypertension so no need to give corticosteroid and high dose this patient is allergic to vulturine and so on you have to bought a summary for it calling it volume number two or one according to the policy in your hostel then you have to keep the very big old one according to your policy for uh what time and we'll call it the overflow record so don't allow the physician and nurses to search in a very very very big medical records you have to make two volumes small volume and big volume the small volume we are dealing with frequently and all the volume is a backup volume another standard number 15 the host will have a system for tracking of the medica record any medical record going out from the medical record department we have to have a system to track it up where the medicare record so you have to have a logbook or something on the system form or something that this medicare record is taken by that department that time and when it come back it come that time when shifted from one department to one department when it shifted and who shifted it and who's responsible to bring it back to the medical record number 16 the hospital used standardized form in the medicare record it's not allowed by any hostel to have two two kinds of one form inside the medicare record for example we are talking about the charge summary form it's not allowed to find two types of it it should be one kind of forms only inside the medicare record if you want to modify it's okay so it should be approved by the medical record the committee then we have to withdraw the old form and give the new form to all department to be used the hostel assign a structure to control the development of the medical record forms which is the medicare record committee medical record the committee is responsible for approving of any new form should be put in the medical and that last the last one is the hospital has a system in place for monitoring completion of the medical record the medical record are reviewed on the ongoing basis we will review the medical record on a monthly basis or a quarterly basis according to the hospital policy the review include a representative sample of course we cannot review all the medicare record because for one month you can find 300 700 and by quarterly you can find 1000 or more so you have to take sample you have to use a standardized sampling technique and which is the most important is the gci you will take five percent of the discharge five percent of the charge within one month or thre months the review is conducted by a cable providers authorized to make entries in the medical record the people who have today to do the review is the people have the authority to document inside the medical record of course physician nurses and so on the review process focus on appropriate and the comprehensive documentation with the timeline lens and eligibility data come out of the reviewing should we should use it for making an improvement projects of improvement activities i will mention it in a few seconds we have two types of uh medical review we have open and close open means the patient is still inside the hostel he's still admitted so we can review the medicare record and we can go back to the patient to ask him anything about the data and we can ask the physician or nurse or the health caregiver about any defects but the clause the medical record review is when the patient is discharged already at home so we cannot ask the patient we cannot find the patients so we will take a sample as we said before five person and we are asking a committee to sit and review it then we have to uh document the results in a special form it's on cebe website for open and closed then we can give it to quality people to help us in making uh charts for what's good what's bad and what kind of improvement we can do and those improvements should be approved by a committee like quality committee like uh medical record committee or the executive committee or medical board inside the hospital before we uh when when to say the medical record is complete if it's containing the demographic data all complete if we have history and the music physical examination assessment comprehensive comprehensive assessment means you do the physical assessment you do the social assessment traditional assessment psychological assessment and everything if we find the progress note for the physician is complete nurses progress not complete physician orders complete laboratory and radiology results uh the charge summary operative note if the patient have surgery consultation forms and reports consents the general consent and the informed consent for operation or inviscible procedure care plan is complete triage forms recall the patient have anesthesia a risk reform if needed admission requests patient and the family education forms medication order vital signs charts nutrition and forms now before we finish our presentation we will ask ourselves a few questions so know that we take any benefit from this presentation or no i'll give you only a few questions you have to about right or true or false and if it's false what what would be the right thing it's very simple it will test your information about this presentation number one surgery department head of department can call medicare record department asking for a release of a medicare record again the head of development of surgery is calling in the medical department please send me the file of this patient or the medical record number 12702 this is correct or not correct who have the authority to do something like this so it's up to your information true or false too medical record is a property of the patient the medical record itself is belonging to the patient it's correct or it's true or false we can use liquid to correct the errors in the medicare record that's true or false liquid all healthy care providers have the right to write in the medicare record anyone inside the hostel can write in the medical record is is it true or false consistency of the medicare record this responsibility of the medicare record the head of department the one is is taking the responsibility of the medicare record department he is he responsible for the consistency of all medical records or not if yes it's okay if not who have uh the responsibility to do this number six the only difference between open and close the medical review is the team who will do it we just mentioned it in the previous slide it's it's the only uh difference between open and the close the medical review is the only team the team who will do it that's the only difference yes or no true or false and that last hostile director should vote his notes during his rounds in the medicare record hospital director is doing a round he finds something wrong in the medical record he will both notes in the medical record this is true or false uh thank you very much for you and until we will meet again in uh a new presentation if you have a question feel free to send it to me uh down here or through my emails if you have my email or phone number thank you very much alaikum warahmatullahi wabarakatuh