A Report On Medical Records

Health teaching will be providing information on disease process and management strategies. Encourage caregiver to set aside time for himself. This could be as simple as a relaxing bath, a time to read a book, going out with friends. Acknowledge to caregiver the role he is carrying out and its value. Teach caregiver to identify how important it is to feel appreciated for their efforts. Encourage care recipient to thank caregiver for care given. Provide time for caregiver to discuss problems, concerns, and feelings. Ask caregiver how he is managing, Inquire about caregiver’s health. Refer to social worker for referral for community resources and/or financial aid, if needed.

Medical Examiners are people who are trained in medicines and whose duty it is to investigate deaths and injuries that occur under unusual or suspicious circumstances, to perform post-mortem examinations, and in some jurisdictions to initiate inquests. Being a Medical Examiner is not an easy job whatsoever. With being a Medical Examiner, there will be many duties, some may include: investigating human organs like the stomach, liver, or brain, determining cause of death, issuing death certificates, maintaining death records, or responding to deaths in mass disasters. Medical Examiners may also assist in violent crime examinations, such as rape

On Friday, November 20, 2015, Investigator Clyde Wheat and I met with Nursing Manger John Wagoner and Lead Charger Nurse Rachel Tarpley on Division 8900, in regards to medication missing from the narcotic lockbox, located inside the 8900 Oncology Pyxis West Room. Wagoner stated the medication was stored in the lockbox Monday, September 21, 2015, at approximately 2345 hours. The medication belonged to Patient Ieremia Fualau. The medication contained approximately sixteen (16) Oxycodone and (17) OxyContin.

A.P.’s strength would be her willingness to learn and be educated about health safety and issues. She is receptive to information about ways to lose weight and how to quit smoking. She is interested in discovering how her health history can show possible future health risks. Her weakness is a lack of knowledge concerning current health problems. She neglects to visit the doctor regularly for medication evaluation or preventative care.

I went to the dentist and followed my aunt. The staff dressed nicely and acted very professionally. Their professionalism was great because they greeted us with a genuine smile. They listened carefully to what we say and answered us with a good explanation. Some steps I could take to create a professional appearance is greeting patients with kindness and care. Another one is to be clean, have your hair out of the way, and don't wear jewelry or wear little. Also, covering tattoos is an important step. Putting on hand sanitizer of some kind when going in and out of patient rooms is also important.

My husband and I were foster parents for ten years. It was very rewarding to be able to take children from an unsafe environment and care for them in a safe and nurturing environment. The purpose of the Foster Care System is for parents or even single individuals to gain temporary custody of children whose parents are not able to do so for whatever reason. In the ten years we fostered we were fortunate to have had only nine children. Sadly though, of the nine children eight of them went up for adoption. The reasons that these children did not return to their homes was strictly because of choices that their parents made. My husband adopted our first placement of a sibling group of three. They went up for adoption simply because their birth mother did not want to comply

The offender is in clinic today for her first visit. She says her right eye has been red and sore for about 24 hours. She has had some watery drainage from her eye as well and she has been rubbing it. She is not sure if she feels like there is something in her eye or not. She denies any trauma. She has had some nasal congestion with her eye situation but she has not had an upper respiratory infection exactly. She has not had any fevers, aches, or chills and she has no history of eye diseases. She came to the facility on 06/20, she had been in the Scott County Jail where she was diagnosed with chlamydia and started on doxycycline which she took for four days. While she has been here, she has had the medication ordered but she has not been taking it, so she has partially treated chlamydia. She also says that she has multiple skin lesions from injecting drugs and her boyfriend has hep C.

Policy Statement: The Medical Record Review Committee is responsible for maintaining compliance of medical records with local, state, and federal standards.

Today there are many issues on the topic of adoption—should the child have rights to see his or her biological parents? Is it wrong to cut off all ties between the child and parent? What about the child’s past, and why was he or she adopted? These are all issues to be concerned with, along with many others. There are plenty of people who have thought on these issues and have even studied into it. Each case will have a different outcome, of course, but overall it seems to lean toward the fact that it should not be legally made mandatory for adoptive parents to allow biological parents’ access to the children they gave birth to.

On the other hand, the nurses, doctors, and the other department facilities should go to the medical record department to improve the documentation quality. Because missing documentation can cause many problems, such as miscommunication, wrong or incomplete treatments, and lower scores from the Joint Commission. Therefore, the medical record officer or the health information employers should identify the missing medical records and then label it, after that, send them to each department in order to complete them.

Some of practical reasons for establishing PHR would be Cost (saving millions of dollars in paperwork flow alone), Updated and easily accessible records, easily communications between providers to provider or provider to patient, and data collecting for many uses to help keep medical information current and efficient.

This patient is a 49 year-old female who required inpatient hospitalization due to nausea, vomiting, and diarrhea. Ms. A came to the Emergency Department with a complaint of two day history of nausea, vomiting, and diarrhea. Two days ago she started to have nausea and vomiting when she decided to visit Emergency Department of St. Luke Hospital where they had given her Benadryl, Tylenol and IV fluids. CBC and BMP were done which showed a WBC count of 1.7. Her symptoms didn’t improve and still continued to have three to four time watery diarrheas associated with nausea and vomiting. She stated to have abdominal pain with intensity of 5/10 in the right upper quadrant associated with vomiting. Her medical history was significant for DM type 2 with neuropathy, cerebrovascular accident, hypertension, and chronic headaches.

A review of his medical record indicates that he suffers from CAD-stable, HTN-stable, BPH-chronic, polyarthritis-chronic, iron deficiency anemia-chronic, GERD-stable and falls. He has noted to be declining functionally and requires more assistance with ADLS.

This paper is on my journey to be Medical Records and Health Information Technician. On every career path there are trials and tribulations that you will have to overcome. With Medical Records and Health Information Technician, you will have to learn skills, abilities, and have to be detailed oriented. Step by step this paper will guide you into becoming a good health information technician by filling you in on my journey. Nothing is an easy journey, but with the proper training and education from the right institution, you will be well on your way in your chosen career path.

I am going to prepare a report on PHR (personal health record), What are its benefits and How it is useful.PHR is an E-device used by the patients to maintain their health information in a safe and secure environment. This stands in opposite to the more likely used e-medical record and data is operated by hospitals and contains data entered by physician or billing data to help insurance company. The proposition of a PHR is to give a total and brief outline of a patient’s health history which is available on the internet. The information data on a PHR may consolidate patient-reported result data, lab results, data from contraptions, for instance, remote electronic measuring scales or assembled inactively from an advanced cell phone.