1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR?…
Schlossberg, B. (2012, March). An easy shift to benefit your practice and the planet. Massage Magazine, (190), 46-49. Retrieved from http://web.ebscohost.com.ezproxy.rasmussen.edu/ehost/detail?vid=3&hid=104&sid=2b51330e-5843-4272-ba93-36c23c748071%40sessionmgr114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=awh&AN=74125048…
DESCRIPTION: The Edict of Worms was a decree issued by The Holy Roman Emperor Charles V banning the writings of Martin Luther and labeling him a heretic and enemy of the state. The Edict was the culmination of an ongoing struggle between Martin Luther and the Roman Catholic Church over reform, especially in the sale of indulgences.…
“A guide to taking a patient’s history,” is an article published in Nursing Standard in December 2007, written by Hillary Lloyd and Stephen Craig. The article provides an overview of the process involved in taking a patient history including factors such as; the environment, importance of following a logical order when taking the history, and communication skills.…
Placing patient information on a chart is a very important aspect of MA's. MA's should try to enter patient information without a mistake. If a mistake occurs, then the MA or the nurse should draw one straight line and write their first and last initial names next to it. After that wright the correct information next to the line. In this case when we look at some don't do , first don't use a white-out to correct the mistakes , don't make multiple cross-outs, and never throw out a piece of information that will indicate we are trying to hide something.…
Electronic Health Records is the technology that I find most beneficial at work. It helps nurses, doctors and other healthcare providers to access patient information literally for 24 hours a day, seven days a week. EHR allows for a better coordinated care for all patients. The information can be transmitted immediately to other providers. EHR allows nurses and doctors to navigate through patients’ data that is far better than pulling charts on the cabinets and searching through pages of the chart to obtain one or two information. The beauty of EHR is that multiple healthcare providers can access the same records at the same time. There are some short comings about electronic health records such as when the system is off line, documentation…
Clinical documentation improvement (CDI) “...is improving the quality of documentation to help ensure an accurate and complete reflection of the patient's care, comorbid conditions, and treatment- which impacts severity of illness (SOI) and risk of mortality (ROM)” (Custodio et al., 2013, p. 56 ). This is an important topic for health care facilities and physicians to ensure it is done well so that the quality of care, reimbursement and financial aspects are correct. “There are several other factors impacted by documentation, including present on admission (POA), hospital- acquired conditions (HACs), and patient safety indicators (PSIs). Some secondary diagnoses are considered complications/comorbidities (CCs) or major complications/comorbidities…
Keeping a spiritual journal is different from keeping a traditional journal. Spiritual journaling keeps account of how a person experiences spirituality in common everyday experiences and in life changing events. The spiritual journaler may keep accounts of seemingly mundane events while excluding the more monumental moments of life. The spiritual journal keeps account of what has made a spiritual impact; the beauty of freshly fallen snow, the sound of a baby laughing or the warmth of the sun shining on one's face. Seemingly insignificant moments can be the trail markers for spiritual journaling.…
I enjoy doing this assignment. In one of my psychology courses I took during my undergraduate studies, we had to do a similar clinical write-up. We conducted two assessments, including the Beck Depression Inventory and the Myers-Briggs Type Indicator. We also conducted clinical interviews and had to write a write-up summarizing the scores of the assessment and created a treatment plan. Before completing this assignment, I thought it would be easy for me to do but, I found that the write-up is difficult because of the specific format it is supposed to be written in. I found myself going back to the examples in the module to make sure that the style of writing meets the standards of a professional clincal write-up one would see in the field.…
Doctor Patient Tracker is useful to record patient’s details along with the compliant. It also records the inpatient details and outpatient details and arranges the appointment of doctors. Doctor Patient Tracker also provides the management reports like schedules, appointments of doctors, inpatients, insurances and discharges. And also used to generate bills dynamically for the discharged patients…
1.2. Engage in social and political action that supports the protection of privacy and confidentiality, and be aware of the impact of the political arena on the health information system. Advocate for changes in policy and legislation to ensure protection of privacy and confidentiality, coding compliance, and other issues that surface as advocacy issues as well as facilitating informed participation by the public on these issues.…
There are a variety of communication modalities available to health care consumers and health care providers. These modalities and venues of communication may entail benefits and challenges to both consumers and providers.…
CDA (Clinical Document Architecture) conveys appropriate information to appropriate person. It is not only a document but also an architecture. CDA usually include text, sounds, images and other multimedia content. There exists variability in clinical notes, degree of semantic coding, use of standard healthcare terminologies and etc. Thus, it becomes difficult to store and exchange documents. CDA standard takes a step closer towards solving these variability. The CDA is a document markup standard that specifies structure and semantics of ‘clinical document’. The CDA is a part of HL7 Version 3 family of standards. The encoding is done in Extensible Markup Language (XML).A clinical document will exist as unchanged for a stipulated time period…
Give a journal to students. They can use their journal to store daily thoughts and reflections. A journal is a great way to promote writing every single day. Students enjoy writing about their own experiences…
is, how we wanted to approach the task we had been set. We laid out some ground rules including;…