Chart Audit Reflection

Two patient verifier completed. Per PA Wu , the patient was informed that she has added an additional bp med to his current regimen. Asked the patient that he has any swelling in legs. The pt says no. Informed the patient that only a 30 day supply was ordered on his Lisinipril. Please record bp readings for the next seven days at the same time then email reading via Micare. If bp in not controlled then a f/u with his provider is needed. The patient agrees and verbalized

Of route, all responsible companies are looking to live on top of HIPAA requirements to avoid hassle while going through an audit, but as threats to patient facts grow, authorities compliance will possibly be the least of your concerns.

Many organizations have developed practice guidelines for a myriad of clinical scenarios which include the use of specific drugs or classes of medications, typically in a step-wise pattern. These “Best Practice” guidelines are built on evidence based criteria and systematic reviews. It has been shown that these clinical guidelines, with their list of essential medications, improve the quality of care and lead to better outcomes, but have not been shown to reduce costs.4,5 The practice of medicine has moved dramatically towards the use of these guidelines in recent years. For example, best practices for diabetic care recommends that all patients be placed on an ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) for prevention of diabetic nephropathy and a statin for prevention of coronary artery disease. However, each patient’s insurance may cover a different medication in this class

Wanda, I am sending this E-mail following our conversation about having Jo come to the CLC to provide an in-service to the staff about "Prosthetic Eye."

Cooper L.A., & Roter D.L., & Carson K.A., & Bone L.R., & Larson S.M., & Miller E.R. III, & Levine D.M. (2011). A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. Journal of General Internal Medicine, 26, 1297 â[euro]" 1304. 10.1007/s11606-011-1794-6

Hello Stephanie! Nurses work the closest to the patients and are continuelly developing and refining ways to bridge the gap between quality outcomes and patient safety. A significant portion of our documentation is recorded on the EHR and error reporting system and since we do know our patients so well this provides an excellent opportunity for the EHR system to monitor for consistent identification of patients who are at risk, a timely communications to other healthcare providers, better decision-making for the care delivery as well as data collection and reporting that all help in the preventing the occurrence of pressure

One characteristic of American culture trough out the years, has been its affinity for diverse weaponry, particularly guns. However, many do not realize that America’s relationship with guns is engraved into the very frames upon which the country was established. In the eightieth century, as a means for hunting and self-conservation during the American Revolutionary War and the American Indian War, it was established with the enactment of the American Constitution that “A well-regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed”, also known as the Second Amendment. (Constitution)

Responsibility Imagine that you’re an amateur mountain climber but one day, you decide you’re going to climb Mount. Everest. Imagine training for months climbing smaller mountains, hiking, and going to the gym so you have some kind of preparation. Soon, the day comes to go on your journey up the mountain. However, to your surprise, the continuous training turns out not to have been enough.

Progress. Over the last decade, the hospital has made a lot of progress regarding the use of HER’s. After the CPSI system was initiated, the transition from paper charts to computer charts began. Today, all charting is done electronically by all members of the healthcare team. From the dieticians to the physicians, everyone is trained and

After finishing interview with standardized patient, I explained everything to my group members and they updated the patient medication chart with necessary changes with discrepancies we found out including plan we came up to implement those

If we have a patient who is dealing with blood pressure issues and needs to discuss plan of action options with the physician we need to block out a double appointment time for this patient. Our next issue is expense. Expense is an issue that is not as simple to handle then that as the patient/physician time issue. We have to have the physicians look deeper into alternative medications to and be more knowledgeable of the patients insurance and what is covered by them at the highest rate. We will also have to take a look at the doubling up of testing there is no reason why a patient should have to pay for a test that was already paid for by the insurance company unless absolutely required.

These programs can be successful when applied but without a physician being required to participate they can be unuseful as it leads to lack of accurate information for public health records. Doctors and pharmacist should both have a legal obligation to check a drug monitoring database and participate further in drug monitoring programs. Doctors and pharmacies should also be investigated for prescribing large quantity of prescription medication resulting in legal action if perhaps they are found guilty of overprescribing. With legislators onboard to curb the misuse of prescription medication this problem can finally be

First goal: Patient will verbalize understanding of the importance of follow her heart medication regime as doctor prescribed it and describe the possible consequence of a non-compliance with her treatment by the end of her today’s appointment.

Another intervention is patient education such as teaching what is considered hypertension, how to check the

As a Graduate Nurse, I have gained over two years of experience within the quality analyst field by auditing, analyzing, interpreting and assessing extensive patient chart records as well as lab results for trends, patterns and/or abnormalities all across hospitals in the province of Ontario such as Sunnybrook, Sick Kids, Center