Obtain Patient Care: A Case Study

• Provide and maintain a safe working environment by the use of safe systems of work

These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.

The Practice strives to provide a safe, healthy work environment, including proper procedures for infection control and protecting employees from exposure to infectious diseases. To achieve this goal the Practice will comply (and will require employee compliance) with all Occupational Safety and Health Act ("OSHA"), Environmental Protection Agency ("EPA"), and State Department of Health requirements, laws and regulations for workplace safety and health.

Recently graduating from Penn Foster’s Career School of the Electronic Medical Records Program; provided me with an overview of how to manage electronic medical records in different healthcare settings whether it is a physician’s office, hospital or urgent care clinic. It also helped me emphasize proper documentation and occupational performance by gaining addition electronic medical records training. My studies and training thus far have guided me in the academic direction that I need to to go into, in order to continue pursuing success.

On Monday, September 14, 2015 at approximately 12:45pm Kathleen A. Kane provided me with information pertaining to Mr. Sutherland whereabouts. According to the hospital records Mr. Sutherland return on 9/11/15 to the hospital and was admitted to 5-Central room 236B located in the Greenberg Pavilion.

The first section to be filled out on the CMS 1500 form in boxes one through 13 include patient demographic information as well as insurance information. This information is captured to ensure the proper claim is associated with the correct patient.

With the elimination of paper charts, patients information becomes available with a touch of a button. This information includes insurance verification, current medications, lab reports, and past visit summaries.

Assessed and recorded patients medical condition and history, skin and wound assessments, medication administration, filled pharmacy orders, submitted specialty referrals for evaluation and treatment through a variety of Electronic Medical Record systems.

What if a single initiative could increase reimbursement revenue, make passing audits easier, and improve patient care? One industry expert estimates two-thirds of hospitals already have this type of program, and are currently reaping the benefits (Rollins). With the implementation of our own clinical documentation (CDI) program, we can join them.

Reviewing current medication use is imperative at each visit. D.E. could have added or discontinued medications with or without her health care providers’ instruction. Asking whether or not D.E. needed to refill current medications could promote medication adherence. D.E. took Simvastatin for hyperlipidemia and Ventolin for chronic obstructive pulmonary disease (COPD). While reviewing the medications and diagnoses, checking labs were also imperative to ensure D.E.’s lipid level was under control. Food, drug, and environmental allergies were reviewed for accuracy.

There are many different departments and programs that are run by the state of Illinois that are potentially related to long-term care and thus should be involved in the integration effort. The first program is Long-term Ombudsman Program which is a resident-directed advocacy program that protects and improves the quality of the individual’s life in various long-term care settings.

Medical Documentation includes all of the patient information for the next health care provider read notes or to over view as a second opinion, here are some examples but not limited to

DOI: 1/1/2014. Patient is a 65-year-old male quality assurance senior analyst who alleges cervical and back pain from sitting on a chair at work. Per OMNI, he was initially diagnosed with cervical and lumbar spine herniated disc.

In today’s highly competitive, value driven, reimbursement challenged healthcare environment, achieving financial targets and conforming to generally accepted accounting principles (GAAP) can prove to be extremely challenging for a hospital. Not-For-Profit (NFP) hospitals face the additional challenge of supporting and defending their tax exempt status. In order to qualify for tax-exempt status, NFP hospitals must comply with the Internal Revenue Service’s (IRS) criteria for tax-exemption which includes (Nowicki, 2015):

§     Comply with and health and safety regulations and co-operate with your employer in his or her attempts to provide a safe working environment