Admin
Covered entities
Healthcare providers, Health plans, and healthcare clearing houses that transmit health information electronically.
Basic duties and workflow
Healthcare workers must possess basic skills, most employers prefer their employees be Cross - trained to perform various duties.
Personal healthcare records (PHR)
Is secure, comprehensive record of healthcare information that is controlled by the patient.
Clinical information
Is the primary source of information about the patient's medical history as well as current clinical information. Clinical information includes: medication list, allergies list, immunizations records, lab reports, Risk assessments, preventative and screening services or recommendations. Progress notes, vital signs growth charts and imaging results.
Professional organizations
Learning should be a lifelong process, especially in the healthcare field where changes A car every day. It is important to stay up to date and connected to others in the healthcare field. The following organizations can help: American health information management association. (AHIMA) - Established in 1928 and now has over 70,000 members. For more information go to W WW.AAPC.com American medical billing Association (IMBI) for more information go to WWW.ambanet.net.
Account Ledger
List services provided, copayments paid by patient, reimbursement received by insurance company (TPP) and balance due. The account ledger shows all financial transactions between the provider and payers (Both TPP and patients)
Lack of inter-operability
Many systems and software are incompatible and cannot communicate with each other, requiring doubted to be entered manually. Standardization is a problem.
MU
Meaningful use
Safeguards
Measures taken to prevent interference within computer network operations.
Coding variance
Medical coding mistakes course by computer or human error
Intro
Medical records have been used throughout history to benefit patients and to advance medical knowledge through research and statistical Data collection. In the past medical records have been paper based now health rackets are capped electronically making data collection use, storage and sharing easier content of the electronic health records The health record is a source document for healthcare professionals and the documentation that provides evidence of care. Complete and accurate documentation is vital to ensure the highest level of healthcare is provided medical documentation is required by law maintaining and ensuring the accuracy of the medical record is one of the most important duties of the healthcare staff. The contents of the medical record may vary slightly, but most contain the same types of documentation.
Coding and claims processing errors
Mistakes that are made by computer error (glitches) or human error range from simple carelessness to incorrect application of coding guidelines and procedures medical offices and facilities should conduct random as well as regular audits. During Orbitz office managers and billers should valuate completed encounter forms (super bills), claims and electronic healthcare record documentation and use to check for proper coding and billing procedures.
Collecting data
Most data initially entered comes from a paper chart. To legally protect the practice, patient information should be gathered from all available sources
Redesigning work flow
Need to see the office as a business being able to adopt a shift and how it conducts that business. With a new system will come a new staff and clinical workflow. Electronic healthcare records of vendors should be able to or from work for recommendations.
Authorization
A document giving a Carber entity permission to use protected health information (PHI). For a specific purpose other than treatment, payment, and operation (TPO).
Encounter
A documented interaction (visit) between a patient and a healthcare provider
Copayment
A fixed dollar amount the patient must pay at the time of the visit copayments are established by the TPP
Encounter form
A form generated to record the services are provided and charges for a healthcare encounter (visit) with a provider.
Soap
A format for recording providers progress notes.
Minimum necessary standard
A key provision of the HIPAA privacy rule requiring that disclosure includes no more than the minimum necessary amount of information to accomplish a given purpose by released.
Hybrid
A medical office in which health records are stored and accessed and various formats.
Hi-alert medication
A medication that poses a heightened risk of injury or death when administrated improperly.
Third-party payer (TPP)
A party other than patient, spouse, parent or guardian responsible for healthcare expenses
No-show
A patient who makes an appointment and either shows-up or calls to cancel the appointment.
Caregiver
A person responsible for providing physical care and emotional support to a person who is ill, disabled or depended on another.
Telephone etiquette
A polite, helpful response and respectful manner toward course.
Patient controlled healthcare record
A portion of a patient portal that contains data entered by the patient, to which the patient may grant or deny access.
Applications software
A program or suite of programs with wordprocessing, graphics, database, spreadsheet, or other capabilities that is used to accomplished work-related tasks by the user.
Audit trail
A record that traces individuals electronic "footsteps".
Host
A server that provides data transfer storage space and other services to users at remote locations.
Workflow
A set of related tasks necessary to complete a step and a business process.
Controlled vocabulary
A standardize list of preferred terms
Encryption technology
A system that keeps dad a secure by converting data into an unreadable code touring transmission
Patient portal
A website that serves as an information transfer head between the patient and the provider.
Compliance plan
A written set of office policies and procedures intended to ensure compliance with laws regulating billing, coding and third-party reimbursement.
Plan for successful transition
Access how ready the practice is for the change. Consider what achievements can be gained by making the change.
Selection and electronic health care record vendor and network platform
Address the practices me it's: A) the choice a company that will be around to provide one term service. B) to choose system that has controlled vocabulary in order to exchange data with lamps, etc. C) to make sure they select and electronic healthcare record that meets a wide range of Industry satisfactions or CCHIT certified. D) a system that has a variety of customization options. E) keep investments at a low cost and operating cost is manageable.
LivingWell
Advanced directive that specifies which life-sustaining treatment's should be administrated or withheld should a person become incapacitated.
Billing encoding
Allow the user to review the clinical documentation while preparing claims for submission electronic health record also aids and billing and coding tests such as submission of super bills, creation of billing statements, assignment of costs, linking of costs to established medical necessity for reimbursement, auditing, organizing office finances, generating prior authorization forms, monitoring claim submission and follow-up.
Virtual private network (VPN)
Allows encrypted data to travel securely through an Internet connection.
Disadvantages of the electronic health record are:
Although the electronic health record is excellent provider tool, there are some disadvantages
Under documentation, over documentation, and electronic miss filing our common problems when information is transferred from paper to electronic:
Both staff and physician should introduce patients to new electronic health record system by following the three C's. . . . Connect, collaborate, and close.
History of present (HPI)
Details related to patient's illness.
DSM
Diagnostic and statistical manual for mental disorders
Views
Different ways displaying same or different information on a computer screen.
Structured data entry
Documentation using controlled vocabulary through pre-loaded data drop-down boxes, radio buttons, and sentence builders.
Physician or other healthcare professional
Documents health history, examination and findings. Plan of care, any other observations made during the encounter, as well as follow-up information
Electronic health record (EHR)
Electronic health record a computerized patient health record that allows the electronic management of patients health information by multiple care providers at various locations.
Privacy - what is privacy?
Electronic health record has changed the way privacy, confidentiality and security are maintained. Policies are put in place to protect consumers and patients from those who may want to use that information for harm. (things like bankcards numbers and test results are stored online). We know the patients must be treated with dignity and respectas well as being offered the best care possible.
Disaster preparedness and response
Electronic health record is a big advantage for an emergency room or field triage unit making it easier to gain access to a patient's medical record. Electronic health record Records are generally backed up and stored at a different location which helps dying a natural disaster like a hurricane Katrina.
Managing electronic healthcare records
Electronic healthcare record is only as reliable as its security features are. It should be monitored daily for system integrity. Maintaining the electronic healthcare record is the responsibilityThe entire office. Maintaining confidentiality is part of the process and systems are frequently orbited to authenticate use the electronic healthcare record.
Time
For employees to become familiar with new systems and software. Employer resistance is another obstacle. Security gaps can cause problems and costs millions in lawsuits under HIPAA And HITECH laws.
Individually identifiable health information (IIHI) (AKA PHI)
Health information that clearly identifies an individual.
PFSH
Past (medical), family(Medical), social history
Advanced accounting procedures
Patient management software includes Peachers to help manage and create patient statements, generate day sheets, and complete claims forms (electronic and paper). An account ledger is a list of the outstanding balance is fullfor all appointments up to the current date. A day sheet or daily journal is a register of daily transactions.
Personal health record versus electronic health record
These are both ways of keeping medical information current. Both or for some sense of protection against loss or damage to records stored in a separate location. Both contain information from various sources (office, hospital, Lab, etc.) The main difference between the two is the one who controls the data entered. The personal health record is governed by a password-protected account data stored is not HIPAA protected unless a covered entity Inc. data from the personal health record. Then it becomes HIPAA Governed and is legal document.
Receptionist or front desk staff
These individuals enter information gathered on the patient information form. Such as notice of privacy practices (NPP). Reason for visit (CC), Co-pays, requests for RX refills, authorizations to release medical information as well as "no-shows", cancellations and rescheduled appointments.
TPP
Third party payer. Insurance company
P-plan
Plan or course of treatment.
Practice management software (PMS)
Practice management software allows electronic management of the business side of any medical practice.
Practice management software (PMS)
Practice management software software used in a medical office to accomplish administrative tasks-not clinical
Developing a plan
Practices agree that the change is in evitable and will be a long but necessary process. It is difficult to start-and electronic health record even if the practice is willing. The process could take months to plan and implement.
Template
Predefined, customizable forms that facilitate structured data collection.
Office procedures that will require a workflow design
Prescription ordering, telephone messaging, receipt, documentation, and review of lab results, recording vital signs, maintenance to do lists, review of clinical notes, patient appointment schedule, cancellations, no-shows, waiting lists, Patient check-In, Patient encounters, patient notification of labs, diagnostic and reminders, decisions on call schedule, new patient information documentation, orders and referrals, authorizations and medical Record requests, HIPAA compliance
Data capture
Process of entering data into a system by recording it electronically and converting it into a machine readable format.
Pre-implementation process
Process of training the staff to implement a new electronic health record system.
Transitioning from paper to electronic healthcare records
Programs focused on improving coordination of care, reducing duplicative testing, and re-warding institutions and providers for a better patient outcomes, improving patient health status. HIPAA Stipulates nationwide adoption of the EHR by 2014. If not adopted fines will be implemented.
Medical necessity
Proof that treatments received were justified for the patient's condition (DX). If medical necessity is not established, claims will be denied.
Closed records
Provider-patient relationship has been terminated patient has moved out of area, provider no longer in network, or patient deceased.
Improve quality and continuity of care
Providers can access quickly their documentation as well as that other providers helping to improve quality of care.
O-objective
Readily seen, perceived, or measured by clinician during examination.
Inter-operability
This is the ability of separate systems all connected to one network that possess The standards of compatibility with others in the network.so far, urgent care clinics have joined an alliance with Microsoft health Vaults which allows patients health vault personal health record. With interoperable systems, some may possess The ability to email information to their visit immediately downloadable to the patient's health vault personal health record. With inter-operable Systems, some may possess The ability to email information to their positions a head of time. Patients can also scan documents like wills into their records.
Audit
Reviews of employment activity within the EHR (Electronic health record)
SOAP
S is for subjective - patient stated problem chief complaint (CC) O is for objective - what a provider observes during examination of the patient. A is for assessment - diagnosing patient or assessing problem for further investigation P is for plan of treatment - patient treatment for further testing
Client
Server model - the interference that allows the client and the server to communicate.
Billing and insurance information
Should include a scanned copy of insurance card at each encounter, type of insurance, claims submission address, phone number, policy and group number, and Cole pay amount.
Entering data
Structured and unstructured data electronic health record systems rely on controlled vocabulary for efficient structured data entry which is a useful way of recording straight forward and clinical findings quickly unstructured data entry allow a provider to describe a patient's history and condition freely and fully. It provides thorough and accurate description of the patient's clinical presentation.
Records management
Systematic control a patient records.
Speech recognition
Technology that convert speech into text
Purging
The process of separating in active patient files from active patients.
Revenue cycle
The revenue cycle is defined as all administrative and clinical functions that contributed to capture, management and collection outpatient services related revenue.
Organizational culture
The shared said about use that governs the organization members as well as guides their behavior and decision marking.
Patient correspondence
There are many correspondence that may be created with in the electronic healthcare record. These would include physcian referral letters, patient instructions, patients letters. Letters in the electronic healthcare record can be prepared from standard templates, or may be created specifically from pre--constructed documents that address specific situations or topics. Some electronic healthcare record systems have functionality to create letters from clinical documentation.
Role of the healthcare professional
There are some basic skills that can help you use the electronic health record: A working knowledge of anatomy, physiology, a medical terminology. Basic typing and computer skills Organization skills Interpersonal and communication skills
Purging patient records
There are three different types of patient healthcare records active, active, and closed.
Health insurance portability and accountability Act of 1996 (HIPAA)
This was made in 1996 with the intent to make a patient's individually identifiable health information kept private and confidential. HIPAA also established the standards for the transmission of electronically sent information regarding the patient's healthcare information. HIPAA also created the privacy rule, security role and security safeguards.
Legal documentation
Through accurate documentation helps prove what, when, where, and why something happened. Proper documentation is important to protect the practice and patient as well as ensure high-quality, comprehensive healthcare. Legal documentation may include: medical records release forms (authorization forms) general procedure and surgical procedure forms, HIPAA privacy forms, advanced directive, disclosure log, and healthcare how are power -of - attorney forms.
Go live
To become operational
Populate
To complete a template or record by filling in a set of predetermined fields.
The main goals of the meaningful use program are:
To improve quality, safety and efficiency of the healthcare information as well as a healthcare provided to individuals. To engage patients, families and caregivers. To improve care and coordination of care,as well as population and public health. To maintain privacy and security of protected health information.
Unstructured data
Typed notes entered into the EHR used to describe an individual patients situation, history for healthcare. This allows greater flexibility for providers to type their Notes in their own words
Abuse
Unintentional deception-not following code rules or standards.
Structured data entry
Use of data that conforms to a controlled vocabulary
Administrative information
Used to perform front office and billing tasks Administrative data includes: patient demographics, emergency contact information, patient referral and consultation letters, prior authorizations, insurance information claims status, billing ledgers, and encounter forms (Super bills, fee slip) Day sheets, appointment history, diagnoses, procedure and HEPCS codes.
Medical assistant
Vital signs, weight, notes regarding chief complaint, medications taken and allergies
Advanced of electronic health record
Well-maintained electronic health record systems can improve quality of patient care in many ways, as well as make data collection, storage, retrieval, and sharing easier and faster
Requirements for electronic health record certification
Were a stab Lish by the office of national coordinator for health information technology (ONCHIT) as part of the American recoveryand reinvestment act (ARRA).
Questions the practice need to ask itself are:
Why make the change and what will be achieved? Can the practice indoor frustration associated with the conversion? Will patient support the change? Can the practice obtain the sources necessary for the change and at a reasonable cost? Is there enough money to keep the practice going while the change over is happening.
Other advantages of the electronic health record are:
easier accessibility at the point of care, bettersecurity, reduce expenses, improved job satisfaction and patient satisfaction.
Authentication
The process of determining whether a person or an electronic health record system is authorized.
Active
patients that have been seen within the past three years
A pre-implementation process
Is a good step and assessing readiness.
Show rate
The percentage of patients in a practice who arrive for their appointments as scheduled or call in advance to cancel or reschedule their appointment.
Documentation
The process of recording data about a patient's health history and health status. Includes; encounter form and insurance forms, all reports (operative, Pathology labs, radiology, etc.)
Patient information form (PIF)
(AKA) patient registration form or intake information that is a form used to gather data about a patient such as: demographic information, medical information, insurance information, and emergency contact information
Day sheet
(Daily, journal, Day journal or daily close) register of all business transactions on a specific day.
Adverse action
A decision by and insurance company to deny or terminate an insurance policy or increased premiums (rates).
Advance directive
A binding legal document prepared and signed by a competent individual outlining a persons health care wishes should be a person become incapitated.
Application service provider (ASP)
A company that provides online access to software applications.
Access to protected health information
Americans seem to be more uncomfortable with others having to collect and access their personal information. We can thank such places as target department store for the compromise of bank card information and 2013. The idea of security breasts on the notion that a patient can choose who gets access to their private health care information In 1999 the federal government really used the financial services moderization act which allows financial institutions like banks, insurance companies, insurance agencies, credit unions, finance companies, account holders, CE companies, Mortgage brokers and check cashers to join together and operate as one entity. Things like payments to medical providers can be openly shared with in the financial supermarkets and can be sold to third parties unless an objection is made by the account holder. New paragraph all companies must disclose their privacy policies and gave customer the right to opt out of these disclosures. *remember, only healthcare institutions are bound by HIPAA laws. The US government is permitted to see a patient's electronic health record without authorization but, only for certain circumstances, like tracking evidence, and the spread of certain diseases. Also exempt or military healthcare plans, workers compensation, Correctional institution's, medical examiners, law enforcement officials, the FDA and national security or intelligence officials.
Acute condition
An illness or injury that is episodic, has a sudden onset, is of limited to ration, and generally responds well to prompt treatment.
Who documents a medical record
An individual who is responsible for inputting information into a medical record is called a documenter or author. The process of documentation includes handwritten, detailed, structured and unstructured data entry, Or downloaded information from other locations. Many different staff members contribute to the patient medical record.
Review of systems (ROS)
An organized (verbal) inventory of each organ system and any unusual findings in patient's medical history.
Medical power of attorney
And advanced directive naming a person to make medical decisions on a patient's behalf should they become incapacitated.
The privacy rule
And establishment of privacy standards for the usage and disclosure of protected health information. The rule helps the patient understand their rights to privacy as well as help them to control the way their information is used and disclosed. The privacy rule took a fact in 2003 and specifies that information requested that is not the purposes of treatment payment and operation must have a patient's written authorization in order to disclose that information. A log of all disclosures must be kept that should include the date of disclosure, the name and address of the entity requesting the information, a description of the information to be released and a copy of The written request
Chronic condition
And illness that process of a prolonged period of time and requires. Follow-up with a healthcare provider
Meaningful use certification
And incentive program for medical professionals who use their electronic health record in a meaningful use way.
Electronic data-Interchange (EDI)
And information exchange technology that facilitates the rapid, accurate transfer of the crypt did data in a standardized format.
E - visit
And valuation and management service provided by a physician or other healthcare providers to an Established patients using a secure on-line system.
Security safeguards
Applies only to electronic health information designated to woodbird security breaches.
Clinical decision support (CDS)
Clinical to scission support allows providers to adhere to published guidelines for patient care for a specific diagnosis (DX) - clinical decision support tools allow providers to: - ensure that the patient's care complies with the Stabley S-t screening recommendations, that the plan of treatment is in accordance with guidelines and excepted practices, help generate patient reports and summaries, complete documentation templates and perform database research. The clinical decision support tools work only if the provider utilizes these functions for excellence in diagnostic imaging utilization act of 2013 now requires the use of clinical guidance tools when ordering diagnostic testing.
Coding systems
Coding systems were developed to standardize the way in which claims are submitted. Medical coding is the process of assigning numeric one alpha numeric code to services, procedures, diagnosis, medical supplies and/or equipment for documentation reporting and reimbursement, purposes. The coding systems used are CPT (4), ICD-10 CM, HCPCS level II as well as NDC (national drug code)
Confidentiality versus Anonymity
Confidentiality refers to how receiving patient information handles that which the patient does not want disclosed. Confidentiality is the assumption that a person is entitled to keep information to himself as well as The provider being obligated to hold all information and confidence Anonymity is to have information collected in a way that avoids any link to the patient.
Consent versus authorization
Consent is patient permission given to the practice to collect and use protected health information for the purposes of treatment payment and operation. Authorization is a patients written permission form requesting entities to haveportions of their protected health information released for reasons other than treatment payment and operation.
Cloning
Copying and pasting notes from a patient's previous visit (Encounter) Into a current progress note.
CDT
Current dental terminology
Electronic transcript
Data entry into the EHR.
Patient demographics
Demographic and Socio economic data such as name, address (home, work), phone, age, sex, marital status, education, occupation and sometimes religious preference, email, social security number, reason for visit (CC), as well as insurance and guarantor information will be collected on the patient information form (PIF)
Appointment scheduling
Depending on office policy, the provider may schedule patients in and variety of ways. The most common is a fixed schedule with specific date and time set prior to the visit. An established patient that has been to the office within the past three years may have an appointment of 10 to 30 minutes. A new patient requires more time and appointments maybe 30 minutes to one hour. Electronic appointment scheduling allows quicker searches, easy rescheduling, documentation of cancellations, and quick links to patient's clinical records.
Electronic healthcare records software
Electronic healthcare records is software and systems have the same basic functionality so uses can adapt to different systems with little difficulty. Basic functions - most electronic healthcare records systems have the following fundamental capabilities Basic functions include: Progress note function, documentation using free Dash text and templates, provider review of incoming lab data and reports, patient correspondence, storage office forms, images and reports, electronic signatures, prescription templates, facts and messaging functions. Reminders to patients, Vital signs, dad are capture, patient portal automatic flagging of abnormal data and testing results, enter office messaging, summary and print functions.
Improved documentation
Electronic transcription using structured data eliminates the need for handwritten Data, also eliminating illegible handwriting and incomplete notes. Electronic documentation reduces data entry errors and helps ensure A more complete patient record. Proper documentation is important to avoid reimbursement delays and denied claims, comply with guidelines, protect the practice from lawsuits, facilitate communication and established evidence of care and medical necessity.
Continuity of care
Encompasses planning and coordination of care, communication between healthcare providers as well as accessability and transportability of the healthcare information
A-assessment
Evaluating the patient's condition and assigning a diagnosis.
Health care reimbursement
For many submitting insurance claims is a hassle and very tedious. Implementing electronic healthcare record should make the process easier. Once you learn the reimbursement requirements, the process is less overwhelming. Working with medical reimbursement means submitting claimsthird-party player including Medicare, Medicaid, and other government plans. HIPAA 5010 is and electronic format that is used to submit claims electronically to receive reimbursement from third-party payers. Submitting claims electronically saves money and it's quicker than mailing claims reimbursement is also received faster: Paper claims-30 or more days. Electronically claims-up to seven business days
Unstructured data
Free data entry needed to describe unique individual health histories.
Double-booking
Give two or more patients an appointment at the same time with same provider
Disclosure
Giving access to releasing, or electronically transfer fine or transmitting information.
Disclosure to family and friends
In this subject, there is been much misunderstanding and confusion with. HIPAA regulations. Healthcare professionals may speak to family or friends about a patient's condition as long as the patient has specified that those family members or close friends can be informed of their general condition, location, death and involvement in patient care If the patient is unable to or is incapacitated, only information directly related to or relevant and to the patient care may be given to family. If it is in the patient's best interest to do so.
Clinical
Includes patient history, vital signs, progress notes, lab requisitions, prescriptions, and test and imaging results.
Costs
Initial start - cost can be expensive as well as operating costs. However the electronic health record saves money in other ways if properly used.
The security rule
Insurance that patient's information is not destroyed by either natural causes or malicious intent. It also ensures that only those who are supposed to have access information will have it.
Fraud
Intentional deception for game-usually money. Presenting claims for services that an individual or entity knows or should know to be false.
Selecting conversion type
One of the first decisions a practice needs to make is to decide if they will switch completely to electronic records management (giving paper rack it's completely) or to make gradual change by becoming a "hybrid" Record office. This means that some of the records will be kept electronically while other portions are kept in a paper chart. This process can take years to convert. Existing patients Will be kept as is until either they pass away or switch providers/practices new patients will already be set up electronically.
Secondary use
Or use of healthcare information that is not directly related to patient care.
Healthcare professionals include
PCP - primary care physician PA - physician assistant (NPP - non-physician practitioner) Physical or occupational therapist Social workers Specialist Surgeon Medical biller
Who owns the medical records (M/R)
Patient medical records are considered the property of the individual or organization that created them in a private practice the provider owns the record in a hospital, Long - term care for facilities (LTC) or a skilled nursing facility (SNF) The institution on the record. However the patient "owns" The actual information contained in the medical record. The patient has the right to access and copy their records by signing a release form. The patient also has the right to request "restricted access", request amendments, and obtain a list of when and who information was disclosed to. A medical practice may legally assign a fee for copies. If the patient believes a false statement has been documented in their chart, the patient can obtain a copy at no fee. One exception to obtaining copies is called The "doctrine of professional discretion." This includes all psychotherapy notes.
Treatment, payment and operations (TPO)
Patient must sign a consent (one) to allow the provider to clinically treat the patient, Bill and receive payment as well as perform any office operations (Procedures and paperwork) to treat the patient and receive payment.
Chief complaint (cc)
Patient stated reason for visit
S-subjective
Patient's illness as perceived by patient.
In active
Patients that have not been seen within the past three years.
Consent
Permission given to a covered entity for use and/or disclosure of protected health information for treatment payment and operation.
Types of personal health record
Personal health record can be either paper-based or electronic. Traditionally these records are paper - based. Patients who want to have their protected health information in electronic form but do not want to store it online can purchase a stand-alone software product that will give them the freedom to create and save all of their protected health information. These online records can be also put into a patient's portal that holds a physician-controlled gateway that allows the patience to maintain their records, but also request prescription refills, then mine themselves and their scheduled appointments, pay outstanding bills toThe provider or other entities.
Administrative
Some administration tests are reception or front desk, appointment scheduling, electronic chart creation, and active chart purging, Gathering and entering patient information, creating patient correspondence, maintaining email communications, providing patient instructions, coordinating patient care with other providers.
Position referral
Sometimes a provider lax expertise or proper credentials to treat a specific problem the patient may have. The provider will then refer the patient to another physician or specialist who is more capable to treat The patients specific condition. A referral form is completed for the patient to bring to the specialist explaining the patients specific needs. It is important to understand that referrals and consultations are two different things every Ferrell is when one doctor sends a patient to another provider for treatment. A consultation is when one doctor asked another doctor (usually a specialist) toreview a patient's condition and treatment then give them medical opinion as to how patient care should proceed Most insurance companies DO NOT pay for consultations.
Managing patients with chronic conditions
Specialists must be able to communicate (share) lab findings, medication prescribed operative notes and other information within the hospital and other facilities or providers. A patient's primary care physician (PCP) must be able to track, organize, store, and retrieve information to provide complete follow up treatment.
There are three parts to a meaningful use program
Stage one - data capture and sharing Stage two - advanced clinical processes. Stage Three - improved outcomes (Not until 2017).
Interoperability
The ability of separate EHR systems to share information and compatibility formats
The role of electronic healthcare record and medical coding
The electronic healthcare record stores complete sets of colds and links them to matching coding labels on a progress note. Codes are updated and the electronic healthcare record system as well. Billing and collections are done with practice management software (PMS) which is usually built - in to the electronic healthcare record.
Assistant
The first person we see when we go to a providers office is the receptionist (AKA - medical office assistant). This is the person who we consider to be director of first impressions. It is so first important that the employee in this position be polite, friendly, and professional at all times. This individual has a big impact on the practice. The impression given can "make or break".
Guarantor
The person who bears the ultimate financial responsibility for a patient's healthcare account balances.
Chapter 8
The personal health record
The EHR electronic health record.
The institution of medicine (IOM) has outlined eight (8) Core functions of the electronic health record. 1- Health information and data management - patient health information accumulated from various locations. 2- results measurements - making test results easily accessible. 3- order management - what a test and prescribe medication electronically. 4- decision support - office treatment guidelines 5- electronic communications and connectivity allows all providers and institutions involved in patients are to communicate and share data involving continuity and quality of care. 6- patient support - tools for patients education. 7- administrative processes - billing and scheduling. 8- reporting and population health infectious disease is can be automatically reported and researches can access and EHR database to gather statistical information.
Confidentiality
The patient's is right that individually identifiable health information will be kept private.
Privacy
The patients freedom to determine when medical information can be released and/or to home the information may be released to.
Patient flow
The patients movement of patients through the medical office or facility.
Patient rights under HIPAA
The patients right to be you or receive copies of their health record The right to have oral in accurate information corrected The right to receive notice of privacy practices The right to opt out of sharing certain information with certain people The right to have certain information withheld from certain parties. The right to receive a list of disclosures of their health related information. The right to file a complaint.
Anonymity
The patients rights to have private health data collected in a way can never be linked or traced back to them.
Why create a personal health record?
This gives the patient the ability to have more control over their personal health record, as well as encourage them to take a bigger part in their own healthcare by being able to communicate directly with the physician through the patient portal. It also helps them to remember things like scheduled appointments. They also offer a caregiver or anyone directly involved in the patient's healthcare to have access for quicker decisions in health related issues.
What is a personal health record?
This is a comprehensive collection of protected health information that is kept in one central location. It is also controlled and maintained by the patient. Both the personal health record and electronic healthcare records keep health information up-to-date by storing all information collected at the physicians visit, the hospital,The laboratory, and other allied health professionals. An important thing to realize is that since the patient controls the personal health record and the patient is not considered a covered entity,HIPAA rules do not apply for privacy protection.
Secure e-mail
This is an inexpensive system (software) that is used to exchange messages through the Internet using encryption. This system helps eliminate news hand written messages that can be lost or missed placed.
Pay for performance
This is an outcome based model, that will reward providers for delivering evidence-based care according to specific standards.
