The Inflammation Theory or Clinical Creations

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

A thorough record of relevant dates is important in determining relevance of past illnesses or events to the patient 's current condition.

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

Your typical work day will begin with an informational meeting so the nurses and doctors can receive their daily reports; this occurs twenty

Accuracy of recordings and ease of understanding of patient information in medical records play central role in quality of

Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness

The field of healthcare administration is growing at a steady pace to bring about efficient service to all the patients (Harris, 2015). Currently, many specialists have emerged to ensure good health to all individuals at affordable rates. For instance, there is the healthcare documentation specialist, formally known as medical transcriptionists, who are highly-skilled health personnel, dealing with the process of transcribing, verifying, or converting spoken (voice-recorded reports) as dictated by a healthcare professional (Skurka, 2017). The prepared report henceforth becomes part of the permanent health record or history of the patient that can be used in future reference.

We traveled to three different sites and used three different documentation programs (in addition to billing programs). I typically would type up a few notes during the day, as time allowed, and complete the rest after all treatments were completed. During the days I was in the outpatient clinic, I tended to have more time available due to canceled appointments. The types of notes that were due for each client depended on their diagnosis and insurance.

Since Mary Knew is new, the documentation should be noted as a new patient (NP) on the schedule. That way the right material is out for the physician. For example, at the wound clinic, we need to get a measuring stick, gauze and saline out for every patient. But if the patient is NP, we need to get out a doppler for the physician. Also, we would need to have the patient some questions. The most important question would be if the patient is on any medication and what for. Also, what the patients medical history? What surgeries have been done and why? Also, family history (grandparents, parents, siblings and childrens medical

6. Patient check-out (collect the superbill from the patient, gather and input the proper codes for the services provided, and schedule any follow-up appointments if necessary)

Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results

This information helps the office maintain records of their patients and behind the scenes can be used to track legal document describing the care rendered,

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.

Upon injury, pathogens such as bacteria & viruses have a means to enter the body.

“Inflammation is a nonspecific, defensive response of the body to tissue damage” says J.Tortora & Derrickson (2011), it is an effort