According to the United States Department of Health and Human Services the Health Insurance Portability and Accountability Act was created in 1996 to protect patient’s information as it is being used to create a higher quality of care for the individual. HIPAAs biggest aspect is the creation and management of electronic medical transactions. When we think of HIPAA we normally think mainly about patient documentation, but HIPAA includes coding. The Medical Coding and Billing Organization tells us that HIPAA’s effect covers to almost every part of the medical billing process, from how records are kept and retrieved to how codes are used in generating claims. Ethics in Medical Coding is the same ethics that cover everything else.
An Advance directive serves as an important set of documents for any individual to have but even more so, for older adults who may potentially be at an even greater risk of hospitalization. Every competent adult has the legal right to be informed of the purpose, benefits, risks, and alternatives of any medical treatment to be given, along with the right to refuse any medical procedures (American Cancer Society, 2015). Advance directive allows for choices regarding medical care to be within a patient’s control and for ease in decision making of circumstances, where unwanted medical treatments and procedures would be used in effort to preserve life at any cost. This legal document also helps to alleviate the burden potentially felt by a patient’s family. As seen with the legal case of Terri Schiavo, a young woman who at 27 years old lived in a persistent vegetative state as a result of cardiac arrest, went through a publicized legal battle between her husband and family to determine whether to discontinue the use of tube feeding (Annas, 2005, p. 2).
all laboratories that perform moderate- and high-complexity tests as identified by CLIA ’88 must participate in a proficiency testing program. Proficiency testing programs measure test. Before collecting a specimen, you must first be sure you have the right patient. Proper patient identification is an essential part of good laboratory practice. You do not want to collect a blood sample from someone who only needs a urinalysis.
HCPCS Level II codes commonly are referred to as national codes or by the acronym HCPCS, which stands for the Healthcare Common Procedure Coding System. HCPCS codes are used for billing Medicare and Medicaid patients and have been adopted by some third-party payers. These codes, updated and published annually by the Centers for Medicare and Medicaid Services (CMS), are intended to supplement the CPT coding system by including codes for nonphysician services, administration of injectable drugs, durable medical equipment (DME), and office supplies. The main terms are in boldface type in the index. Main term entries include tests, services, supplies, orthotics, prostheses, medical equipment, drugs, therapies, and some medical and surgical procedures.
Two forms guide the Medical Power Of Attorney: the “Living Will” and “Advance Medical Directive” and clearly indicates what course of action the patient would want taken in medical circumstances. Several states unite the Living Will and Durable Power of Attorney for healthcare into an "Advance Health Care
It recognises the conflict between beneficence (provision of multi-disciplinary care, provision of training to medical students and postgraduate trainees) and confidentiality (disclosure of the medical record). The GMC (2009) notes that, most patients understand and accept the need to share information within the healthcare team that support the provision of care. The GMC also recommends that this information should be made readily available to patients in the form of posters, online or face-to-face and be tailored as much as possible to the patient’s needs (GMC, 2009). It is thus now recognized that the “patient-doctor” relationship has been largely supplanted by the “patient-healthcare team” relationship (Ferguson, 2012), and that information disclosure should take place in a manner that is consistent with the “spirit” of patient confidentiality (Anesi,
Medication reconciliation assignment was an individual activity that I had to perform as a part of a course requirement. For this activity, we had clinical simulation lab organized with standardized patient. In simulation lab, I had to refer patient’s chart that includes his home medications and then interview standardized patient and get all detailed information regarding his medication schedule including name of medication, strength, dosage form, route, frequency and any adverse event associated with any medication patient is taking. After interviewing patient, I had to update patient’s medication list in to the patient’s chart and based on my clinical knowledge if I found any discrepancy in the patient medication list then I have to come
ARTICLE #9 Legal Concerns Regarding Medical Record Alteration: The Proof is in the Metadata From Coverys Risk Management (Timothy Malec, Manager, Claims) With the advent of new technological systems and the passage of the Patient Protection and Affordable Healthcare Act, electronic medical records have been widely adopted by many healthcare organizations. While there are many benefits to electronic medical records, such as better access to patient data and improved preventive health, there are also issues that arise due to the application of this technology. Particularly when it comes to medical malpractice litigation, problems emerge when healthcare providers don’t understand the implications of their actions, like accessing and changing
This process begins with the patient’s first contact within the healthcare system. If this is within an outpatient area, the patient is assessed (often utilizing interpretation phone) for their primary language or the language they feel most comfortable receiving and giving information. If they are identified as LEP, it becomes part of the permanent record. Because of hospital policy, which is based upon Title VI, Civil Rights Act of 1964 and the US Department of Health and Human Services, Culturally and Linguistically Appropriate Services (C LAS) standards, the LEP population must be offered translation services during any interaction within the medical
One of the greatest changes that took place in 2002 when the FDA proposed a new ruling that introduced the use of bar codes on drugs in the hospital setting. The bar codes had to match the patient profile when administering at the bedside (Strategies to Reduce Medication Errors: Working to Improve Medication Safety, 2015). In December of 2003, safety reporting was proposed by the FDA. This would require the submission of all suspected serious reactions for blood and blood products, and required continued reporting of important potential medication errors by all medical facilities and providers (Strategies to Reduce Medication Errors: Working to Improve Medication Safety,