CHAPTER 5 Content of the Patient Record: Inpatient‚ Outpatient‚ and Physician Office Chapter Outline Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review Key Terms addressograph machine admission note admission/discharge record admitting diagnosis advance directive
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no decimals and are used the most often. Each code has a descriptor which describes what each code represents. These codes represent procedures that are consistent with contemporary medical practice and are widely performed. Both doctors and outpatient providers use Category I codes. There are six different sections of category I codes – they are as follows: 1. Evaluation and Management 2. Anesthesiology 3. Surgery 4. Radiology 5. Pathology and Laboratory 6. Medicine
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divisions has a different job in which it oversees throughout the organization. Their central offices are predominantly in Washington D.C.‚ although they do have some in Colorado‚ Texas‚ and Maryland. This does not include the many VA Medical Centers‚ Outpatient Clinics‚ Vet Centers‚ and Benefit Offices scattered throughout every state. This works well for the VA because with this structure not one department is covering all of the workload. Also‚ this structure spreads everything around so that each
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Federal and Specialty Hospitals. 2-A: Inpatient Hospital Unit Data - General Acute Care Only. Beds Set Up & Staffed‚ Admissions‚ Days of Care‚ and Occupancy Rates for each of 18 inpatient units. 2-B: Inpatient Hospital Unit Data - Same as 2-A for Federal and Specialty Hospitals. 3-A: Discharges and Discharge Days by Age Group - General Acute Care Only. 3-B: Discharges and Discharge Days by Age Group - Same as 3-A for Federal and Specialty Hospitals. 4: Emergency services capability and utilization
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FACILITIES PROVIDED IN PRIVATE HOSPITAL 2.10.1 CUSTOMER SATISFACTION Yang (2003) outlines some methods of measuring device service quality from both the Customer’s perspective and management perspective. SERVQUAL is a model developed by Parasuraman in 1993 based on “gap model” which defines service quality as a function of gap between Customer’s expectation and the actual delivered. This method widely used by scholars and practitioners. The other method to measure service quality is Customer Surveys
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Concerns related to the absence of trauma informed care practices on an inpatient psychiatric unit. Observation of some staff members quickly resorting to restraints as the first intervention during an escalation of a patient. Inadequate training of staff on how to de-escalate patients. Failure to use least restrictive alternatives as a primary option. Deficit in knowledge/understanding on how to de-escalate a patient. The metrics that would be used to evaluate this clinical problem would be the
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Theoretical Orientation: Outpatient Treatment Programs Marilyn Ramirez Hunter College There are several treatment modalities available for individuals with substance abuse disorder. It’s wonderful that there are so many options to support people with substance abuse issues (SUD). The road to recovery is so long for most people and finding the most suitable treatment program can be greatly beneficial to the client. On the other hand‚ starting a treatment program that is not the best
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Hospice General Purpose of the Department: As we have learned‚ the hospice idea is not new. Literally meaning "given to hospitality‚" hospices provided comfort‚ kindness‚ and nourishment to people in need hundreds of years ago. Today‚ hospices offer comfort to people as they near the end of life’s journey. Hospice is a special way of caring for people with terminal illnesses and their families. It is a multidisciplinary health care program that is responsible for palliative and supportive
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Checkpoint History of State and Federal Prisons Krysta Nasce CJS/230 1/09/2013 Instructor: Richard Angelozzi What is the history of state and federal prison? Prisons‚ unlike jails‚ confine felons sentenced to longer then a year to serve their sentence within the facilities. They are operated by state governments but the Federal Bureau of Prisons also houses federal offenders in Federal penitentiaries. Since its establishment of prisons within the United
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The medical billing process is when claims are filed to insurance companies requesting payment to providers who rendered the services to a patient. There are ten steps to make this process that we went over earlier in the class. Those ten steps include preregistering the patients‚ establish financial responsibilities for visits‚ check in patients‚ check out patients‚ review coding compliance‚ check billing compliance‚ prepare and transmit claims‚ monitor payer adjudication‚ generate patient statements
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