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
Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the
Accountable care organizations (ACOs) are consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth.
In the health care system, there are a lot of codes that help diagnose, treat, and discharge patients daily. Codes help nurses
What is the Accountable Care Organization? “Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients” (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html). The ACO is a component of the Affordable Care Act (ACA). “The Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act or ACA, and generally referred to as Obamacare – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010” (www.healthinsurance.org). One of the main reasons the ACO mainly focuses on Medicare patients because due to the aging, their health problems will become chronic disease and that will have an impact on the healthcare cost years to come. It is stated that about 78% of the total health care is spent for chronic diseases.
MEDICAL CODING QUALIFICATIONS AND CERTIFICATION Medical Coding is a career in which professionals use numeric and alphabetic codes to help submit and process medical claims. The coder abstracts information from the patient records and combines that information with coding guidelines to assign the right code for the information provided by physicians, hospitals, and other healthcare professionals. Insurance companies look at these codes to understand the diagnosis, treatment, and prescriptions for proper payment of these services. Accordingly, the medical coding profession requires a worker to have a strong grasp of numbers and be detailed oriented. (AC Search & Media, Inc.)
The article Alternate Health Care Coding Systems gave brief descriptions and examples of alternate coding systems. All the alternative coding systems and medical nomenclatures are used as another way to properly diagnose patients, and proper billing and reimbursement. Although, I was a bit confused retaining all the information but in my take away from the readings is that nomenclatures and coding systems are used to allow medical terminology, codes, procedures, and diagnoses to be more descriptive. Two patients could have the same exact tumor but depending on size and where the tumor originated from could be the difference in coding that certain patient.
An Accountable Care Organization or ACO is a group of doctors, hospitals, and healthcare providers, who voluntarily come together and provide coordinated high quality medical care to Medicare patients.
Accountable Care Organizations (ACOs) are group of physicians, hospitals and other healthcare providers coming together voluntarily to deliver high quality healthcare to patients. On the other hand, American Hospital Association (2010) defines ACO as legally structured arrangements between hospitals, specialty physicians and/or primary care and other healthcare providers to facilitate effective and efficient healthcare for a defined patient population. Typically, ACO focuses on assisting patients with chronic disease to get right care at the right time with overall goals of preventing medical errors and unnecessary duplication of healthcare services. More importantly, ACO focuses on delivering high quality healthcare at low costs. The Health and Human Service (HHS) estimates that ACO could assist Medicare to save more than $960 Million in the first three years, which will assist Medicare to spend healthcare dollars more wisely. (Centers for Medicare & Medicaid Services.2012).
Amanda I agree that altering or destroying medical records is illegal but also unethical. Destroying medical records can cause serious issues regarding patient safety and can create a vast amount of work for the patient as well as the provider. I agree that there would be a breach in confidentiality if a medical record was improper discarded, it raises questions as to why the record was destroyed in the first place, and if discarded incorrectly could make the patient vulnerable by giving individuals’ unauthorized access to their records.
Being fluent as a Billing and Coder in Medical Terminology is very imperative to the success of our career. One slip up because of a incorrect term can lead to a number of different issues, and most importantly it can lead to rejection and non-payment which is a big NO for the office. There are even simple terms that can be mixed up. According to Quizlet some terms that are commonly mixed up are 'ilium and ileum' 'palpation and palpitation' and 'viral and virile' just to name a few (1).
Electronic medical records (EMR) software is a rapidly changing and often misunderstood technology with the potential to cause great change within the medical field. Unfortunately, many healthcare providers fail to understand the complex functions of EMRs, and they rather choose to use them as a mere alternative to paper records. EMRs, however, have many functionalities and uses that could help to improve the patient-physician relationship and the overall quality of patient care. In order for this potential to be realized, both the patient and the healthcare provider must have a deeper understanding of EMR purpose and function. In this paper will highlights the historical developments and its potential effects on the patient physician relationship in order to
The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)
EHR in its simplest form is a digital version of a patient’s paper chart. EHRs have been defined as “real-time, patient-centered records that make information available instantly and securely to authorized users”[19]. It can allow patient information to be more easily shared between clinicians in different organisations, such as between ???, thus improving patient safety and clinicians’ decision-making.[20, 21] EHR can be combined with an electronic prescribing system, which can provide clinical decision support to physicians in the form of highlighting tests that are abnormal and advising on the ordering of specific drugs for the patient.