A Case Study: Chief Compliant Data Entry Screen

For established patients receiving evaluation and management, providers may bill for these services using the CPT codes 99212, 99214. Choosing the correct code depends on the patient’s history, examination findings, and decision-making complexity. If complexity is found to be straightforward taking the provider less than 10 minutes, the billing code will be 99212 (Engle, 2014). If the history and examination findings result in moderate decision-making complexity, requiring more time from the practitioner and more diagnostic procedures the billing code will be 99214 (Engle, 2014). While, Ms. Trinidad does not encounter established patients in the emergency department, within my clinical hours, Ms. Rossow encountered several established patients of various levels of complexity. The billing code 99212 is appropriate to use for patients with low complexity, such as one of Ms. Rossow’s patients whose visit was due to elbow pain after a fall a week ago. Mrs. Rossow also managed the care of patients with a higher level of complexity such as a middle-aged male with a history of recent prostate cancer and a chief complaint of abdominal pain and fever.

You are letting the provider know what the patient chief complaint or reasoning is to be seen at the office that day. All information the patient has prior will be beneficial for the process of the claim.

The basic reason for this study is to identify ways to improve the quality of healthcare among patients through bedside reporting method.This will better satisfaction and services delivered at the hospitals. The ever increasing specialization to improve patient outcomes and better health care delivery can contribute to the serious riskof fragmentation of care and problems with handoffs. These are some of the issues associated with emergency room reporting method (Radtke, 2013). There is need to evaluate the handoff method used in hospitals and understand which is the best way to use that increases patient satisfaction. Bedside handoff gives the patient an opportunity to contribute to his or her plan of care. It allows the nurse to visualize the client and as necessary questions regarding their health status. This is the reason there is a need to conduct research on bedside reporting.

The problem list is a key part of the electronic health record. It lists the patient’s most important health problems and gives the practitioner key information to determine the best treatment plan. Accurate patient problem lists

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

21. Report any unusual or major changes in your patient’s health, cleanliness, physical care, actions and

One of the greatest milestones in the United States health system is the use of electronic health records codes to ensure consistency in diagnosis and treatment procedures provided by physicians (Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who visits the emergency department is to show how electronic health record coding is done and its impact on health reimbursement. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) codes are brought out well in the case study showing how they help in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of health reimbursement.

    The modern day emergency room is a department that is constantly busy. In the hustle of caring for patients, there are some details of the patient’s care that can be overlooked in a standard phone report to the accepting nurse. With this in mind, a change is needed so that there is an optimum patient outcome for each and every one of the people that walk through the doors of the emergency room and get admitted.

- One of the issues is the fact that Senator’s are appointed by the Prime Minister. In other words, senators are appointed to the Senate for being loyal to the Prime Minister’s party which is seen as undemocratic and gives the Senate an illegitimate image.

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

There are many types of data collected, such as, Demographic, financial, socioeconomic, and clinical data are collected from patients so that the healthcare providers of services to the patient are able to assess the history of whatever disease the patients is suffering from and how is to be treated. Data collection in the facility is well organized in a way that promotes shared assessment, treatment and communication. Nurses and front row staffs collects raw data’s from the patient, and. The Heath Information Manager and team are the facility are responsible in analyzing and presenting the data collected in a meaning and easily understandable way to served the specific purposes for which it was collected. Examples of such data are, patient’s name, height, weight, gender, allergies, and third party

-Documented patient information, including medical histories, neurological deficits, and exam results, to present to the head ER physician for use in determining subsequent steps

Common complaints like a sore throat is noted as one of the most common complaints for which individuals seek care. The ailment can be related to simple conditions like pharyngitis, laryngitis or tonsillitis but may be associated with more complex conditions and require the implementation of a thorough patient history and physical examination to provide both a timely and accurate diagnosis for the patient to promote optimum patient outcomes (Shepherd, 2013). The condition may also be related to pathogenic infections or environmental exposures (Ruppert & Fay, 2015). First and most importantly one must obtain a thorough history including information related to the onset of symptoms, duration and the severity of the condition, past medical history and current medication history because this information may account for 80% of the information related to the final diagnosis (Shepherd, 2013). Other criteria which must be obtained before diagnosis includes a review of systems during the history and physical exam of the throat, tongue, tonsils, neck and abdomen which includes identifying the presence of pertinent symptoms (Shepherd, 2013). Utilization of resources like the Centor score to determine the need for antibiotic

Accurate and comprehensible medical records documents are crucial for a positive outcome for the patient and health care providers. Health records sequentially convey significant details concerning patient’s health history and future care plans. These records are pertinent when initiating care in the acute and chronic setting for the patient. Medicare, Medicaid, and other personal health care providers necessitate rational documentation to guarantee that a procedure and/or examination is consistent with the individual’s health care coverage. The documentation also authorizes the place of health care treatment, eligible medical requirement and suitability of diagnosis and/or therapy, and that the services rendered were appropriately documented. Precise and reliable medical documentation should be recorded at the time of treatment or shortly after the intervention. Inappropriate documentation can result in erroneous and inappropriate imbursement for provided health care services.

Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the right