Blossom Creek Documentation Paper

PART I: MEDICAL RECORDS QUESTIONS The Medical Record Management System your office implements is only as good as the ease of

NUT1 Task 1 Western Governors University NUT1 NUT1 Task 1 What is EMR? Electronic Medical Records “a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)

Patient documentation is an essential element in patient safety. Failing to adequately document patient information not only affects the quality of care provided to the patient, it posses a legal risk to the provider and the institution, and affects reimburse levels.

Medical treatments require a great deal of paperwork. Before patients are allowed to go through treatments, a clinic must process their insurances, medical records, and surgery details. As a result, a lot of private information is gathered within the hospitals. With so much private information, it is essential for healthcare facilities to efficiently organize their paperwork. An unorganized recording system can prove disastrous to a hospital. Leaving patients’ paperwork publicly unattended and misplacing a file are both considered negligent. Misplacing patients’ information can potentially lead to information theft and invasion of privacy. An efficient way of storing information can be valuable in preventing HIPAA

The Development of the MS-DRGs System Maria Anna Fernandez HIT 230 - Health Insurance and Reimbursement October 1, 2017 DeVry University Online Professor George Fisher The Development of the MS-DRGs System According to Rosenbaum et al. (2015), healthcare documentation combined with clinical communication that is coded for hospitalized patients is an important part of medical care. The paper or electronic healthcare record is then submitted to third party payers that provide reimbursement for services based on the guidelines of the Centers for Medicare and Medicaid Services (CMS), Medicare Severity Diagnosis Related Group (MS-DRG), and inpatient prospective payment system (IPPS) (Rosenbaum et al., 2015). The

When external requests come from an acute care hospital or nursing home for the release of information (ROI) for a patient’s medical records, various procedures take place. The ROI clerk must be knowledgeable of all the federal and state regulations and any laws that are involved. Whether it is paper-based, hybrid, or electronic, the procedure is still the same. The patient must sign a consent form or letter of authorization and must be accompanied by the request form to have any documents released. Upon receiving this request, the ROI clerk enters the request in a database to log the request, then needs to ensure the forms are valid before the patient information is released. Once the patient has been verified, then, only the specific information

While these tools theoretically address well-known requirements for and common errors associated with clinical documentation, mismanagement can often create information integrity concerns. Health care systems must have processes in place to ensure all digital documentation used in care, research,

There are inherent risk and benefits of hospitals utilizing electronic medical records. Three problems that could occur involve workflow, registration and drug interactions. The aforementioned are problems that spill over into the other because they are interrelated. This is caused by inconsistency among “disparate systems,” communication between departments and errors involving medication (Gartee, 2011, p. 183).

Risk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Electronic medical records (EMR) can improve healthcare performance and cost efficiency in healthcare facilities. Improving healthcare performance includes patient safety, quality of care, and health status of the patients. Patient safety with medication errors continue to escalate, costing health care systems billions of dollars each year (Seibert, et al., 2014). An estimated 450,000 adverse drug events-medication errors that result in patient harm-occur annually, approximately 25% of which are preventable (Seibert, et. al, 2014). Overall, having an EMR helps improve healthcare delivery: no illegible handwriting, information can be shared on an instantaneous basis within a healthcare institution or between institutions, and review of previous

Abstract In the United States, the American Recovery and Reinvestment Act has mandated that all medical records be converted to an electronic format by 2015. Promises of improved availability of patient information, enhanced efficiency and cost-effectiveness are a few of the factors that have steered the need for this conversion.

Information system (IS) is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and present information that support the organizations. Information systems are complex system and therefore it is essential to approach their acquisition, implementation, and management with proven methodologies (Burns, Bradley, & Weiner, 2011, p. 389). System acquisition refers to the process that occurs from the time the decision is made to select a new system (or replace an existing system) until the time a contract has been negotiated and signed (Wager, Lee, & Glaser, 2013, p. 210). The Agency for Healthcare Research and Quality (AHRQ) plays an important role in the acquisition and

Introduction The benefits of Electronic Medical Records (EMR) significantly outweigh the disadvantages, when it comes to the nursing care of patients in multiple settings. There have been multiple studies proving the enhancement and efficiency of nursing care in various areas, when electronic documentation is properly taught and utilized. Likewise, there is evidence supporting the reliability of the documentation, after comparing nurses’ verbal accounts of previously recorded information. When the programs used in electronic documentation are continually evaluated for completeness, accuracy, and quality, they become excellent tools for legislation. Electronic medical records present many advantages to the nursing care of a vast majority of patients, and also help uphold satisfactory legal and ethical implications of nursing documentation.

The challenges I see in implementing a portable health care record are (a) Patient’s not wanting to change from paper to electronic records, they want to stick with what they already know, (b)Patients and staff having negative feelings to the portable records without even trying them, (c) Communication issues may arise between staff and the mediator, (d) and staff may have difficulty with patient education because not all patients know how to work with electronics.

Strategies of Nursing Documentation to Promote Patient Safety Introduction Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.