Initial Intake Assessment Paper

The VA Outpatient clinic has MyHealthE Vet, which is an online system that allows veterans to access their medical health record from the outside of the facility. The veteran can access lab records, medication, schedule appointment and treatment plan, which allows patient to have a continuum of care (My health,

4. While they are being seen by the physician, an encounter form is bing filled out regarding the symptoms, diagnosis, and treatment of the patient. This form will then be given to receptionist at the end of the visit.

Once established many issues arise, for example, any outside doctors need to be approved prior to the veterans visit, and this creates, even more, problems because it was too much “red tape” on the process. The other issue was that Congress estimated that it was too costly. To replace the veteran's choice VA and Congress decided to implement “MyhealtheVet”, the program permits veterans to search a variety of methods to improve their health and gain a better understanding of their overall health status. The program provides veterans with a number of tools and resources to evaluate, monitor and access medical information from any location that internet is available. The program directly connects veterans to their health care providers to make sure that they are getting the best medical assistance possible. Sometimes, the only thing that the veteran needs is a prescription refill, before they have to wait for a doctor’s appointment just to do that, now using My HealtheVet they send a message directly to the doctor and he or she let the pharmacy know of the patient needs. The veterans can pick up the prescription at the pharmacy or the prescription can be mailed directly to their homes (United States Department of Veterans Affairs,

Once the Authorization for the Use and Disclosure of Protected Health Information is complete, the medical record assistant will retrieve the request from a system called, Fax Finder. It is an electronically fax, that is placed on a computer desk top, and retrieves the request forms daily. The request forms are sent from physician offices, patients, and legal matters. After retrieving the request for example, a doctor’s office is requesting records that state the patient is cleared to return to work, after successfully completing a heart stint, the medical record assistant, will then access, Greenway (electronic medical record), and input the patients first and last name, and date of birth. Once the office note is located that states the patient can return to work as normal, it is then electronically faxed to the doctor’s office that was requesting the

My clinical site utilizes an electronic medical record. This system is integrated with the nearby hospital system. Information is placed directly into the patients’ electronic medical record (EMR). Details related to the history and physical are entered as information is obtained during each visit. Behavior and psychosocial details get recorded in a standardized template such as a SOAP note.

An interview should be conducted with the patient prior to giving a patient an initial appointment, this allows the office staff to collect preliminary data to ensure that the patient has called the appropriate office for an appointment and to verify the patient's eligibility. Insurance of the patient and the status of benefits. In this call the following information should be collected;

Patient is due for her influenza and pneumococcal vaccine. Patient educated on both vaccines especially the pneumococcal vaccine in regards to her having a chronic condition Diabetes. Patient also given literature, patient at this time declines for personal reasons. Patient cervical cancer screening is not due until 12/6/2015. Patient also due for breast cancer screening, order written, patient will call to set up appointment. Patient up to date on tetanus, next vaccination is 1/1/2016

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

- Patient's name, address, phone number, birthdate, reason for appointment, and if the patient is enrolled in an Insurance

In a general medical record a patient is entitled to a copy of his or her record, the only thing they would have to do

Prepared documents for the meeting. Sorted and filed by discharge ready for long term patient. Assign and billed, filling a chart order and photo. Perform duties in human resources, organized account payable files, and employment documents. Focused on filing and sorting medical records. Improve business skills in communication, know-how, knowledgeable, teamwork, and communication. Focused on teamwork with Health Colorado. Forwarded bills

The electronic medical record (EMR) is basicly the patient’s medical record from an individual medical practice, hospital and or pharmacy. It does not go outside from the facility where it was created. Whereas an electronic health record (EHR) is the patient’s electronic medical record from multiple medical practices combined into one database. The electronic health record can be view outside from where it was originally created. The total practice management system is a software category that handles all the day-to-day operations of the medical practice.

How many of the medical facilities do you see out there that use a paper medical record system? Do you ever wonder if there is a better way, than to fill out all that paperwork, and wait for a phone call back for missing documentation on one patient’s record? There is a better answer, and we are going to talk about it in this paper. It is called an EHR. There will be the pros and cons of both an EHR, and paper Medical Records.

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital