Integrated Care Documentation Sample

Each student selects a different Case Study and notifies the instructor via email on your

Clinical documentation Improvement (CDI) is the program or the training that is design to provide the good link between coders and health care providers that increase the accuracy and completeness of patient health care documentation. According to American Health Information Management Association (AHIMA) tool kit CDI is the program especially design for health care field for initiate concurrent and, as appropriate, retrospective review of patient health records for accurate, incomplete, or nonspecific provider documentation (Scharffenberger and Kuehn 2011). Most of the time patient health record review occur in inpatient location but it there is any confusion then the review can go through electronic health records too. CDI play a vital role solving complex case between coder and health care provider that result in easy and smooth operation of reimbursement process in health care organization for the service they provide to patient.

Healthcare delivery system in recent times is confronted with a lot of problems, cost, accessibility and quality of care. To be able to address these problems, healthcare organizations rely on information science technology to enhance cost-effectiveness, and safe quality care.

Health Information Exchange (HIE) has become a major component in today’s healthcare. Health information exchange provides a secure way for providers to appropriately access and electronically share a patient’s medical information. Therefore, reducing duplicate testing, minimizing medication errors and providing a link among electronic health records (EHR) in order to provide quality healthcare.

broad range of individual patients. The patient should be able to benefit maximally from the care he/she receives.

Case Management Society of America. (2010). Standards of Practice for Case Management. Retrieved from http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may

Our Surgery Coordinator will take care of all our patients' insurance issues prior to surgery to make the stress of the financial issues less for our patient before entering surgery. He or she will speak directly to the patient about his or her scheduled surgery and pre-op instructions.

The research studies reviewed all share a common theme that staffing and patient care make a safe care environment. The patient safety conditions all are enhanced by adequate staffing and nurse retention. Nursing turnover leads to reduced staffing and affects the patient’s outcomes and overall satisfaction. The point of agreement is that nurse staffing and the environment has a positive effect on patient safety, outcomes, and satisfaction.

Question 2: I provide almost all of the care for assigned patients throughout the shift but may not have the same patients from their admission to discharge

The patient is 22-years-old Travis Walker, who is happily married to Emma. Travis had a boating accident and suffered a spinal cord injury at the level of C-7. He believed his health condition was excellent until the boating accident. Travis’ medical records indicate he had tonsils removed at the age of 3. He is currently at a rehabilitation facility, three weeks after his accident.

The United States has developed into a diversified nation that is comprised of numerous perspectives, values and health behaviors which are creating health disparities within the health care system (Cowen & Moorhead, 2012). Failure to address these disparities could evolve into considerable health and cultural concerns among these minority groups. Nurse leaders have to be cognizant of these concerns and implement culturally competent standards of care in their organization to reduce inconsistency of access to quality of health care in the United States. For implementation of a cultural competent care in an organization to take place, the leaders must comprehend its meaning and impact in their

Carecloud is great for long hours of the day, making your time more efficient. CloudCare allows you to view how long a patient has been waiting for and what rooms are open. In the initial conversation with the staff from the UMUC clinic, the first complaint was the amount it time it took to check a patient in and the inconvenience of having to run around to notify the provider. With the CareCloud, allergies are acknowledged and will let the provider know if a patient should not take a certain medication. Carecloud also lets you discontinue medications.

The connections between auditing, accurate diagnostic and practical coding with CDI programs is that the clinical documentation improvement (CDI) is that revising and monitoring offers oversight for the CDI program, understanding into physician documentation and collaboration, and objective assessment of the performance and efficiency of individual CDI staff members as measured against the facility’s policies and

Throughout the years public health efforts evolved to meet health care needs of populations. Despite those advances, the United States continues to have high morbidity rates of chronic illness. In addition, many Americans are suffering from mental health disorders. The issue caused many research studies to focus on integrating behavioral health and primary care in order to reduce health disparities in the nation. This paper analyzes how the integration of behavioral health in primary care facilities help serve the need of our population.