Patient Detect Audit Analysis

After finishing interview with standardized patient, I explained everything to my group members and they updated the patient medication chart with necessary changes with discrepancies we found out including plan we came up to implement those

Every fiscal year the Clinical Nutrition Manager creates a proposed chart review schedule for Outpatient Dietitians to follow (S. Kulshrestha, personal communication, March 9, 2017). For instance, if the outpatient chart review schedule is: Marcia Monica Stephany Gail Marcia; then Marcia will review Monica’s patients charts for three months, Monica will review Stephany’s and so on. Every month the peer assigned for the audit will review a different patient’s chart. The Assessment Diagnosis Intervention Monitoring and Evaluation (ADIME) audit for Outpatient Dietitians performed at the Miami VA is intended to follow the same competencies, regulation checks and audit procedures required by the Joint Commission (S. Kulshrestha, personal communication, March 9, 2017). The ADIME audit patient chart reviewing includes documentation on assessment, nutrition diagnosis, expected outcomes and reassessment (Appendix A). The mock audit I performed was based on the Joint Commissions Standards and the ADIME

Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report.

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

The health coach performs multiple activities that currently require the coach to manual pull data from the electronic medical record, EHR. With this redesigned approach the health coach would no longer complete chart reviews as the EHR that is currently used throughout the clinics have a patient manager section that includes all of the information that is being manual extracted for the chart reviews. Also, instead of the health coach manually pulling data, such as who has been in the ER five or more times in the past year, set up a report that will run automatically on a monthly basis for the coach to review. Finally, the health coach is currently pulling the data on hospital discharges manually on a daily basis. In this process the health coach opens all of the charts of the patients that were discharged the prior day to determine who the patients primary care provider (PCP) is and

expected. Moreover, the admit source for 19 out of the 27 admissions was an ER visit.

The key to providing high-quality healthcare is to have a complete depiction of a patient’s health record. Collecting comprehensive patient data is vital in forming a complete picture of a patient’s health record. It can help for improvements, and measures it for the intended use; for cognitive support to help integrate the data; to integrate evidenced-based practice guidelines and research; to build patient portfolios and for physician diagnosis; for continuing education for knowledge and treatments; to involve patients and their families into medical decision making in order to ensure accurate and consistent data; and to generate reliable information. To ensure that there are useful, reliable, and resource-efficient quality data in healthcare,

On January 13th 2017, at 15:46 Supervisor Tatiana Kania performed a screening audit. While Security Officer Ruth Gonzalez was on main screen S/S Kania walked away from the desk and came back with her cell phone inside of her hood. Once coming through the metal detectors, S/O Gonzalez instructed her to secondary screening. At secondary screening the S/O instructed her to take out everything from her pockets and began to wand. She was able to find the cell phone in the hood area. I specifically chose this area because with observation I noticed that some guards do not fully go up to the neck on the back side while wanding.

Slid out of his wheelchair to the floor witness by staff. Back lounge monitoring staff observed patient sliding out of wheelchair to lie on the floor. Patient stated, "I wanted to lie on the floor because it helps my back. I put myself on the floor because of my back hurting. I don't need to go to the ER. I just need to lie down." Patient denies hitting his head while sliding out of his wheelchair, no visible bruising, no signs of bleeding noted. VS obtained. Patient advised that he can lie down while in his room. Patient noted getting up from the floor stating, "I'll go to my room and lie on the floor in my room." POD, NOD, CN notified of patient sliding out of his wheelchair so that he could lie on the floor because of his posterior back.

Table 5 summarises the national number of patient assessments which showed each of the four harms and which showed none of the harms – ‘harm free’ - for the period from March 2015 to March 2016. It should be noted that a patient may have all, some, one, or none of the

AAPC was founded in 1988 to offer education and professional certification to physician-based medical coders and to lift the standards of medical coding by providing training, certification, networking, and job opportunities. AAPC offers 32 certifications about the whole business side of healthcare, including professional service coding (CPC), professional billing (CPB), medical auditing (CPMA), clinical documentation (CDEO), medical compliance (CPCO), and physician practice management (CPPM). It cost for individuals $160.00 annually, for students $90 if you are an AAPC student or $110 for non-AAPC student. If you are a corporation it will be $950.00 a year and $95.00 each add on. AAPC offers training for all stages of a healthcare career,

Medical auditors perform audits and reviews clinical documentations, physician billing records, administrative data, and coding records. They establish compliance within the industry regulations and maintain quality assurance. You can work at a medical facility along with other auditors, medical office managers or even an accountant.

Documentation Type: Provides an extensive list of document formats to make charting and documentation easier. The templates include forms for treatment planning, progress goals and initial assessment.

The aim of the Nursing and midwifery council is to regulate nurses and midwives in England, Wales, Scotland and Northern Ireland.(Nursing and Midwifery Council, 2016). The NMC is set to protect the public and to represent and campaign on behalf of nurses and midwives. (Nursing and Midwifery Council, 2016). Furthermore the NMC regulates healthcare setting and hospitals,regulates healthcare assistants and also set staffing level to ensure high quality of care the first time round for service users.(Nursing and Midwifery Council, 2016).

The purpose of a clinical audit is to improve the quality of care in the NHS (Healthcare Quality Improvement Partnership, 2011). To assist practitioners in changing practice to match the rapidly evolving evidence base guidelines are issued by organisations such as NICE (Fineout-Overholt & Melnyk, 2011). However there is often a gap between recommended practice and current practice which leads to lower quality care (Courtney &