Jane Dares Health record Abbrev.

Used the same program to chart patient vital signs, assessments, input and output, safety and medications among other requirements.

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

B. Define the abbreviations found in the surgical report. How did you find the meaning of these abbreviations?

Attached is a copy of the EPIC glossary. I included the entire glossary only because the Event and Type of the 10/4/14 and 10/15/14 spreadsheet are abbreviated explanations of what actually occurred within the patient's medical record.

The date the examination/assessment/evaluation was performed for the presenting diagnoses. Or, if following the applicant for an extended time, the date of onset and date of an evaluation of the condition that is recent enough to demonstrate the applicant's current level of functioning.

Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92.

Answer the following patient information questions using the table provided. Refer to figure 4-10 on p. 83 of Health Information Technology and Management for assistance.

“Patient DeAnn Kyte, forty-four years old, Caucasian, female.” That is how I imagine her doctors begin to dictate their notes from her chart. DeAnn Kyte is a patient diagnosed with Chronic Fatigue and Immune Dysfunction Syndrome. She is also my mother.

Under HIPAA, the DHHS established a set of codes for identifying diseases and procedures when healthcare transactions are submitted electronically (Ong, 2011). According to AMA (2015), the appropriate International Classification of Diseases (ICD) code and Current Procedural Terminology (CPT) code must be accurately documented to comply with HIPAA, which begins with scheduling the patient’s appointment. For example, to schedule an office visit for a patient diagnosed with a mental disorder referred for neuropsychological testing, the following codes must be documented when scheduled: Dx: 294 [CPT 96116 (2 hrs)] & [CPT 96119; Tech 183732 (3 hrs)].

Most of the three character codes you’ll see will be category headings. These codes would then be expanded into four, five, or six characters to add even more specificity about diagnosis.

Procedure Abbreviated, patient case or treatment type. Gives an abbreviation of what procedure patients is arriving for

This healthcare is documented meticulously and examined scrupulously. Data from the care given is extracted, gathered, and computed. These statistical analyses are interpreted. Trends are identified, and action plans are assembled.

This policy covers common terms and abbreviations used in TB, as well as the procedure related to conducting cohort reviews.

The last two I looked at are AID (artificial insemination by donor) and AIDS (Acquired Immune deficiency syndrome) while the majority of people know what AIDS is, I had no conception that AID was even an abbreviation and just by leaving out the “S” could affect the way the patient is treated. If the patient is pregnant by AID but provider reads it is AIDS they could potentially hurt the baby and mother by giving a medication that should not be taken if pregnant or nursing. There are several abbreviations out there and just with one mistake such as incorrect capitalization, missed punctuation, or missed a symbol any of them could possibly cause grave consequences which is why it is so critical to be aware specifically to detail because you never know if it could take someone's life or cause a lifetime of health

iv  List of Abbreviations ................................................................................................................ v  Executive Summary ............................................................................................................. vi  INTRODUCTION ....................................................................................................................... 1  1.1  1.2  1.3  Background  ............................................................................................................. 1  . Statement of the Problem ....................................................................................... 2  Objective of the Study ............................................................................................. 2  General Objective ............................................................................................ 2  Specific Objective ............................................................................................ 2