Kaiser Permanente has been equipped since 2007 with Health Connect; which is the largest private electronic health record implementation in the world. This is a highly sophisticated electronic program that integrates inpatient, outpatient, and clinic medical records with appointments, registration, pharmacy, and billing for all kaiser members. In addition, this electronic program includes an entire medical library with a whole set of care support tools which are accessible to doctors, nursing staff and patients (Kaiser Permanente, n.d.). At kaiser permanente; nurses are expected to print out “the after-visit summary” (AVS), which contain the doctor recommendations for each patient that we see.
This information is used to appropriately implement prevention and treatment for patients. The second outcome integrates analysis of information gathered by healthcare personnel to identify trends and inconsistencies within the healthcare population. Through this the origin of problems can be ascertained, and preventive measures can be instituted. Subsequently prevention will decrease incidences and ultimately the cost to
#1- Compare and contrast the clinical uses of a health record with the secondary purposes of a health record. The use of Health Records are used by both, clinicians and non-clinicians (secondary purposes). Reasons to why clinicians may use a patient records are for confidential data such as patient care (diagnosis and treatment), chronological documentation of clinical care, method of cross discipline education, research activities, public health monitoring and for quality improvement activities. In contrast, non-clinicians may use is for non-confidential informational data such as billing and reimbursement, verifying disabilities, and legal documentation of care.
Medicare reimbursement is partially based on a facility’s Star Rating. A critical component to this is patient surveys and HCAHPS. I have seen a push toward the customer service experience. Indeed, I feel strongly that every healthcare worker including nurses should treat each of their patients with respect, equality and do the absolute best to meet their needs.
The National Practitioner Data Bank (NPDB) is an electronic information clearinghouse used by health care professionals and authorized organizations where data is collected and managed It contains data on medical malpractice payments and certain adverse actions related to health care practitioners created by congress in order to improve health care quality by preventing fraud and abuse and encouraging patient safety. The website offers a place where authorized users such as health care professionals and organizations are able to submit negative reports confidential that include medical malpractice, Negative actions or findings by a peer review organization, Negative actions or findings by a private accreditation organization, Health care-related
Demonstrate effective use of technology to navigate the electronic health record, communicate with inter/intraprofessional teams, and be involved with decision making in the delivery of quality and safe patient care. (Ivy Tech Community College, 2016). Rationale In nursing, the use of technology is vital in providing high quality of care and complete understanding of the patient.
The NPSG and the Joint Commission survey have a positive relationship with each other. Implementing and achieving the NPSG would in turn lead to a possible good survey results due to the facility implementing steps to make the care that the patient is receiving safe. There can be serious consequences for a facility is the facility is not meeting the patient safety goals. Multiple tools are out there to help the facility assess the readiness for the Joint Commission survey. There are multiple actions that this author could put in place to make sure the organization is ready for the survey and to make sure the organization passes the survey.
To lay the groundwork for portability, this rule set standardized codes and formats for the interchange of medical data and for administrative purposes. HIPAA mandates two types of codes for the transfer of data. First and most importantly, uniform codes are needed to describe diseases and injuries, describe the causes of the diseases and injuries, and to describe the preventions and treatments used. Secondly, there are smaller sets of codes for many administrative purposes—for describing ethnicity, the type of facility or the type of unit where care was performed. As much as possible, the major codes have been chosen based on code sets that are already in use, known as "legacy
• When retrieving information from a nurse to update the patient 's file, never share that information to another nurse even if a question is asked. It is against HIPAA, and if a fellow employee overhears, it could cause possibly termination. • When asking a patient to update his demographic information on paper, be sure do it when other patients are not around. Scan the sheet immediately into the computer and dispose of if correctly in a shred-bin located in either zone of the emergency department. • When a family member of a patient comes in to the emergency looking for that patient, be sure the family member can verify the date of birth and first and last name of the patient they wish
It is my responsibility to have admission and continued reviews done promptly and accurately to determine whether the patient meets medical necessity for inpatient or outpatient status. I review all patients’ charts, especially those in an observation status. They are reviewed frequently and in real-time to ensure they are actively being managed and in the correct status. Observation patients are given priority in order to catch patients that may be discharged. Collaboration continues with the physicians and if there is a question about status, the chain of command listed above is followed.
It is given to patients randomly throughout the year, collected by those who receive training in giving the survey. Some questions that are asked are in the category of composite topics which include; nurse communication, doctor communication, responsiveness of hospital staff, pain management, questions about medications, discharge information, and cleanliness of the hospital. This is all done to show the patient the true quality of the hospital, and the general effect on the
Electronic Health Records and Patient Confidentiality Technology has become an essential part of our everyday life therefore, it makes sense that doctors and hospitals get rid of the old fashioned paper charting and use technology to access patient records. Electronic health records (EHR) provide quick access to information, as doctors no longer have to wait for other providers to fax previous records to them. The accessibility of Electronic Health Records assist medical providers to make quick medical care decisions, by accessing previous care provided to patients including treatment and diagnosis. Quick access to information through EHR enables health care providers to treat patients faster as there is no need for records to be mailed or
The anxiety of seeking and receiving health care is worsened when patients are unsure of how to find the radioilogy department, clinical laboratory, or other facilities. When clear written directions accompany verbal directions, along with easily readable signage, way-finding is perceived as much less troublesome. This, in turn, enhances the overall service quality perception. Gracious problem solving: Given the nature and complexity of health care delivery, it is no wonder that problems tend to occur.