Case Study: Medical Records

On Tuesday 06/27/2017, veteran Mr. Saenz walked very angrily in my office with his wife about 11:00 AM. I greeted them and offered to sit down; Mr. Saenz and Mrs. Saenz were very upset and asked me where they need to go as they have VA examination, they both said “nobody tells them anything; they have been sitting in waiting room”. They told me that the lady on the desk told them to come to me.

This paper is intended to summarize the objectives of HIPAA in safeguarding the privacy of individual’s private health information from unauthorized access in general and security requirements for HIPAA compliance in particular. The HIPAA privacy rule requires covered entities to protect patient’s health records and any other identifiable health information by using appropriate safeguard to protect privacy. The HIPAA security rule requires that covered entities implement a security technology to safeguard the integrity, confidentiality and availability of individual’s electronic private health information while exercising quality service for patients. Healthcare providers have shifted towards the use of electronic health records

On 7/27/2015, HOH and client attended to ILP meeting with their daughter Emily. Child was observed well dressed for the weather. Client explaining to cm that her floating hospital was cancel and she doesn’t know the reason.

HIPAA privacy rules protect patients ' privacy and provide patients access to their medical records. The security standards include certain integrity, privacy, and physical safeguards component, protecting computer systems and network system from physical intrusion and hazards. This security measure is headed in the right direction to display the steps needed to protect all data and procedures by regulations. With HIPPA rules in place, an individual has the right to request any of the entities that the electronic protected health information shows that are not accurate. To ensure al privacy steps has been taken it will involves communications between the medical organization database medical staff and the patient who has requested information to remain as secret. A Good example would be when an individual give medical office his work number to use as a form of communication , in place of his or cellular or home phone number.

Agencies required to follow HIPAA regulations must implement steps to maintain the security of patient health information. Safeguards include key card systems to track the individuals who have access to protected health information and secure electronic transaction systems to ensure any information sent electronically is equally protected. Limiting the disclosure of information to certain individuals is another way to protect health information, notes the U.S. Department of Health & Human

Medical documentation is important to know and complete properly to ensure that the office or practice you are employed with does not get flagged during an audit. Paying close attention to detail is key!

The risk of protected health information being breached has grown dramatically within the past few years, and to combat the threat, the HIPAA Security Rule was created to provide organizations with administrative, physical, and technical guidelines to safeguard their electronic personal health information. These rules have spawned courses of action that healthcare systems can implement to thwart breaches on patient health information such as:

For a nation to be technologically advanced, the United States (U.S.) is having a hard time overcoming the dark era of utilizing hand written scripts, progress notes, and paper records. In comparison to other countries, the U.S. is lagging behind in the health care system. Even with all the improvements that have been made recently, the U.S. ranked last in 2014 in areas such as access, efficiency and equity compared to Australia, Canada, France Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom (Davis, Stremikis, Squires, & Schoen, 2014). Now, as our nation is trying to improve the quality, access, and proficiency of our health care, concerns have been raised whether the new policies are adequate enough for privacy amongst sharing and obtaining health information. This paper was put together to give background information on how the electronic medical record came about and whether privacy is a major concern amongst the American population.

As seen in this case study, TM was listed as a full code and no GOC conversation was had between the physicians and the patient until the day of his discharge to home. This led to an unnecessary swallowing study in which the patient needed to be uncomfortably scoped. Due to the lack of GOC conversation the patient also chose to go home with general nursing services instead of end-of-life (EOL) hospice support. In the inpatient medical oncology floors of a large teaching hospital like this one, most patients are covered by rotating interns and residents that are not comfortable having GOC conversations with patients and leave it up to the primary physician to come and discuss.

1. I do believe that large pharmaceutical companies as well as doctors prescribing opioid medication should be held partially responsible in cases when patients are over-prescribed drugs. Although they are in no way actually forcing those patients who are over-prescribed these drugs to misuse them and it is ultimately the fault of the individual misusing the medication, they are, however, allowing for the the misuse.In regards to pharmaceutical companies, I think that they should be held responsible for marketing and allowing such drugs available to virtually the mass public opposed to only those that need it in order to increase their profits. If they would not advertise the medication to medical professionals as something that they could

These records make up part of the hospital’s information system. Said information systems must be readily accessible and will include all necessary information including, human resources, financial information, and most importantly medical records. By updating a patient’s record and making it readily available to all health care providers, the information system allows a flow of information from one department to the other; without risking the loss of paper notes on the way (Pozgar 2007).

Then plaintiff realized that on January 03 2017, she suffered a minor stroke due to exposure to CO poisoning and as of result lack of oxygen to her brain, stroke is a disease when the brain is robbed of oxygen. It was approximately 700 over-flights from January 01, 2017 through the early morning of January 03, 2017 and at that time plaintiff’s heart and breathing condition were in a very bad shape.

Electronic Medical Records or Computerized Medical Record System what is it and what are the advantages along with the disadvantages of using this system? That is what we will discuss in this paper.

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

Mrs. J. arrives at the emergency department with her 6 year old son, PJ, who has a history of Cystic Fibrosis (CF). He is febrile (101.7° F orally), BP 98/66, HR 122, RR 32 with the use of accessory muscles. Mother states PJ has, for the last five days, exhibited signs and symptoms of upper respiratory infection, runny nose, low grade fever, cough, and fatigue. He has lost 2 pounds over the past 5 days due to anorexia though he has not had vomiting. He weighs 36 pounds and height is 3’2”. Today, PJ became more lethargic and his fever was difficult to control with pyretics.