Physician Query Process

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

When the referral is received from a physician outside the healthcare provider’s network, paper medical records relating to the health issue are requested, including office notes and test results. After the patient’s paper medical records are received by the scheduling office, the scheduler manually reviews the records for the diagnosis and reason for the referral to determine how to appropriately schedule the office visit. For example, if the patient recently suffered a stroke, the patient would be scheduled with a stroke specialist rather than a general neurologist.

The finding of the survey exposed that an important factor of administrative complication was probably due to the number of different contracts a physician was in agreements with. The question was

Ambiguity and lack of regulatory control is echoed in David Powner’s article published in the Lancet Journal: “Clinicians do not always follow an established policy or provide appropriate documentation. Surveys or chart reviews showed that doctors sometimes failed to document specifics of clinical examinations, omitted criteria demanded

Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in

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.

When external requests come from an acute care hospital or nursing home for the release of information (ROI) for a patient’s medical records, various procedures take place. The ROI clerk must be knowledgeable of all the federal and state regulations and any laws that are involved. Whether it is paper-based, hybrid, or electronic, the procedure is still the same. The patient must sign a consent form or letter of authorization and must be accompanied by the request form to have any documents released. Upon receiving this request, the ROI clerk enters the request in a database to log the request, then needs to ensure the forms are valid before the patient information is released. Once the patient has been verified, then, only the specific information

This service, once the patient is identified, searches for the existence of records within the exchange. This form of information retrieval would be very helpful to the care of a patient, most specifically in the case of emergency care (Morris, 2012). The Emergency Dept could begin a query at the time of triage to build a problem list, allergy list, medication list, current physicians and ongoing treatments. The costs associated with developing a record locator service, and the questionable sustainability in a market lacking interoperability between the available EHRs, have impeded the development of this form of exchange (Rudin,2014).It has been difficult for HIEs using this format to reach their tipping point to become self-sustaining. There are several determinants driving the success of Query-based HIOs – the need for a broader set of clinical data, more diverse and high-volumes of data, obtaining relevant users that need the database, and utilization rates (Morris,

More documentation is required from this patient. The three components of an encounter are (history, examination, and medical decision making). The nature of the presenting must also be documented. An established patient is a person who has been seen by the physician or group member within the last three years. Only two components of the three key components and the nature of the presenting problem must be documented in the established patient's medical record (Andress,

2. Relevance- Make sure that the services provided actually pertain to the patient's health condition.

In contrast to hospital A, the results reveal that the only guide that some of its questions have not been implemented in hospital B is Patient Identification. There is only one recommended practice in this guide that has not been implemented. Some of the recommended practices in the following guides have been partially implemented in hospital B: Clinician Communication, Contingency Planning, High Priority Practice, Organizational Responsibilities, Patient Identification, and System

The chief compliant screen will allow clinicians to enter patient’s reasons for visiting the emergency department. The chief complaint data entry screen will be to obtain information from patient such as symptoms, duration of symptoms, and what major problem they are experiencing as a result of symptoms. The chief compliant data entry screen does not deals with obtaining information about chronic illness or history of family disease. Rather, the data entry screen will enable clinicians to prioritized treatment intervention based on severity of patient’s condition. Furthermore, the data capture in the chief complaint entry screen can be

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.

Coders must ensure the accuracy of the claims they submit by using valid diagnosis and procedure codes. Also with the roll out of ICD-10 they should be using the highest level of specificity (Fortney, 2014). Claims must be submitted using the current approved CMS-1500 (02-12) form with uppercase letters. The insured name must be listed in addition to the patient’s name if not the same. The patient’s name must be listed by last name, first name, followed by middle initial, commas can be used, but no periods. Additionally, the patient’s name must be entered as it appears on their insurance card. The address should be entered on three lines without the use of punctuation. Birth dates are required to be in an eight digit format. If information is not applicable it should be left blank and n/a should never be entered in the field. If a provider fails to enter the insured information correctly or omits information it could result in a rejected claim. If it is necessary for a provider to request pre-authorization for services or supplies that authorization number should be entered on line 35 field 23 (CMS, 2012). There are occasions where a payer may request supporting documentation to back up charges that have been submitted. The provider must ensure each page of supporting documentation has patient identifier information in the event it becomes separated

What I think is missing from the provider’s page is a personal information blog about who they are and where they came. I would like to know what inspired them to become a doctor. I think that if they have any lawsuits or malpractices should also be public information. This information is important because people would want to know if the person was competent enough to take care of them or if the issue was a misunderstanding. I also think that how many years they have been practicing is also important. I understand people must learn but if a person has multiple healthcare issues then that might be too much for a newly minted provider to take on and then they would start referring people out unnecessarily. I would like to know if my provider speaks any other languages because I know people who don’t speak English and if I feel like my provider is a good one, I would like to refer people to her. There wasn’t a list of other hospitals that the provider was practicing at. I, personally think this information is important because I had a provider who was at multiple locations and she always seemed worn out when I went to see her. I didn’t think that this was fair to me