Medical Justification Report

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.

The Medicines Act 1968, the Misuse of Drugs Act 1971 (and later amendments), the Misuse of Drugs (Safe Custody) Regulations 1973 (and later amendments), the Health and Safety at Work Act (1974), COSHH, the Mental Capacity Act (2005) the Access to health records Act (1990), the Data Protection Act (1998) plus equality legislation.

Documentation is “as important a skill to learn as our occupational therapy practice techniques” (Brennan, 2015). Proper documentation should enable us to articulate rationale, demonstrate clinical reasoning, clearly communicate information, and keep track of client progress. It may also help promote the field of occupational therapy or at least provide greater insight into what we do.

In the article “Legalize Use of Marijuana for Medical Purposes, MDs and Patients Plead” Charlotte Gray discusses the controversial topic of medical marijuana, while appealing to the reader’s pathos by using emotional stories about patients. Gray, an editor for the Canadian Medical Association, claims that marijuana needs to be legal for medical purposes and doctors should have a supply available for patients. However, Gray does not offer a convincing argument due to the amount of focus on appealing to people’s emotions, while not providing supportive details, statistics, and truthful pathos.

In the medical office, there are several types of occurrences that may require immediate invention by the medical assistant. A few examples include:

A medical consultation is a consultation, which takes place between a patient and a physician. It is important because it is the main opportunity for the doctor to explore the patient’s problems and concerns. However, respect and kindness between the physician and patient should be in consultation.

The Department’s Representative LB testified that the Appellant filed an application for MA and HCBS in February 2017. The Application was initially submitted electronically and then a paper application was received. The MA/HCBS combination application was initially denied for failure to provide verification of an emergency medical condition. The Department realized that the Appellant had case activity on two different record numbers therefore, requested new medical information and the application was reviewed again. The IMCW testified that on April 25, 2017, the medical information was received and sent to the Office of Long Term Living (OLTL) for a determination; the following day, they requested additional medical

A visit that I would like to talk about is with my 44 years old Hispanic male patient at his workplace. He has a history of diabetes and prehypertension, so the purpose of my visit was to evaluate how he was doing, and to educate him about nutrition and exercise to maintain good health. My patient is married man and has three children (8, 12, and 16 years old). His wife is a stay at home mother, and he is the only person working (as a car mechanic) in the family. He is a Spanish speaking patient, so a translator and one of my classmates accompanied me for this visit; however, he was able to speak and understand English decently. In the Hispanic population, heart disease, cancer, unintended injuries, stroke, and diabetes are the top causes of death (Allender, Rector, & Warner, 2014). Also, hypertension and obesity are major concerns in this population, and Hispanics are twice as likely as Whites to be diagnosed with diabetes (Allender et al., 2014). More Hispanics live at the poverty level, have lower level of education, and have higher uninsured rates compared to other racial groups

Medical error reports can vary by type of error, for example, rule violations, non-standardized medical practices, medication and diagnostic testing errors, management practices, patient misconduct, and insurance fraud. Research suggests that many medical errors go unreported and that nurses are pivotal in understanding barriers to reporting and ways to improve the reporting process. Nurses are believed to a critical part of the medical error reporting issue because they are the individuals that work hands on with patients (the most), have a duty and responsibility for patient advocacy, and changes, resulting from error reporting, that improve direct patient care practices impact nurse’s day to day actives (Wolf & Hughes, 2008). Evidence suggests

A medical necessity letter is a legal doctrine that can only be written by a physician. These types of letters are usually written up to verify medications, treatment course and/or if the patient needs certain equipment. This is all based on evidence based clinical standards of care.

Reasoning that is considered a systematic approach to moral conflict and is directed toward analyzing an ethical dilemma, generating alternative solutions, and determining actions to be taken is known as ethical reasoning (Willard & Schell, 2014). I will rank the sixth clinical professional reasoning with a three. The current strongest form of reasoning for me is interactive thinking, which is the seventh clinical professional reasoning listed. This form of thinking is directed toward building positive interpersonal relationships with clients, permitting collaborative problem identification and problem solving (Willard & Schell, 2014). The last clinical professional reasoning is known as conditional reasoning and it is the blending of

If you are looking for a birth injury lawyer in Pennsylvania then you have come to right place. The birth of a child is a festive event but if a child suffers from birth injuries due to medical negligence it can be emotionally very devastating to a family. If you suspect that your baby were harmed by a preventable medical error, a medical malpractice attorney will evaluate your medical records and review your legal options with you, for that you need to hire a good birth injury lawyer with a decent to deal with your case.

In your grievance filed at Browning Unit, you claim you are not receiving timely responses to your medical grievances. You further assert that the responses you have received are not resolving your issues. Your resolution is for the medical grievances to be processed by

Identifying that improved partnership with doctors is precarious to refining medical care and health in our societies, and that medical center currently employ roughly 20 percent of all physicians, the American Hospital Association (AHA) Board of Trustees created a group in 2010 to give guidance in recognizing means and arrangement policies explicitly for doctors who work thoroughly with medical centers. The group suggested that AHA implement four arrangement plans: instruction, value and protection, leadership expansion, and encouragement and community strategy. Now in 2011, the AHA’s Physician Leadership Forum (PLF) put into operation with instructive assistances, means, and management growth prospects for doctors, as well as selections for

     Imagine yourself lying on an operating table, motionless, quiet. Above, you notice people standing over you. You try to speak but the words just cannot come out. Your arms feel as if they are plastered to the table. You begin to stand up but feel as if weights are strapped to your back and you are bound to the table. Suddenly you feel a sharp pain in your midsection. In and out, you see a surgeon slicing your body open with a scalpel. Every motion the masked person makes is as if you are being torn apart from the inside out. One would hope this would simply be a nightmare and they will wake up and everything will be fine. In this instance, this person will