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Medical Records!

Transcript: By: Jessica Hernandez The upside of electronic records are that records are faster to find unlike the paper files where you have to take time to find, and now you could even send out electronic prescriptions to the pharmacy and it is faster to get your medication instead of waiting for it for an hour or more. Also a paper file can get lost or stolen, and a electronic records can't because you would need a password or code to get in them. Changing records from place to places is something you should be careful with, make sure you put it back where it belongs. Filling out medical records!! Electronic health records are medical records saved in computers, to me this makes it easier to look up a patients chart, you won't have to worry about people misplacing the patients chart. When someone is organizing a medical record, they have to make sure that they are doing it the correct way, making a mistake while organizing a medical record is bad. When one is organizing a medical record, they should always make sure they do it in alphabetic order so it can be faster for someone else to find it, always make sure you put it back where it belongs so you won't misplace it. When an employee is filling out a medical it is really important that they fill it out with correct writing and it has no mistakes, or misspelling, that might confuse some one else later on. How To Organize Records! Organizing Records! When someone has to change something in the medical record, they have to know that they do it correctly and that they have the correct information, like if the patient has a number or address change make sure it is correct. And you fix it so the next time it will be changed. Changing records! Electronic Records! Paper files are a way to file a patients file you file them by putting them in alphabetic order by last name, but sometimes it takes a longer time to look for a patients record, and it is a faster way to misplace the record or even loose them. Medical Records! Paper Records! Changing records! Filling out medical records! You should always make sure when you fill out medical record that some one like the doctor makes sure everything is correct before you organize it where it goes.

MEDICAl RECORDS

Transcript: By:LIZETH Medical Records OUR COMPANY OUR COMPANY IN DETAIL Introduction Medical Records and Documentation play a big role providing quality for patient care. TREATMENTS TIME LOCATION LOCATION STAFF Doctor's Name Nurse’s Name STAFF Nurse’s Name Doctor's Name Nurse’s Name Nurse’s Name PRODUCTS & SERVICES PRODUCTS & SERVICES PRODUCTS PRODUCTS IMPORTANT PRODUCT FEATURES 1 IMPORTANT PRODUCT FEATURES 1 IMPORTANT PRODUCT FEATURES 2 IMPORTANT PRODUCT FEATURES 2 IMPORTANT PRODUCT FEATURES 3 IMPORTANT PRODUCT FEATURES 3 SERVICES SERVICES IMPORTANT PRODUCT FEATURES 1 IMPORTANT PRODUCT FEATURES 1 IMPORTANT PRODUCT FEATURES 2 IMPORTANT PRODUCT FEATURES 2 IMPORTANT PRODUCT FEATURES 3 IMPORTANT PRODUCT FEATURES 3 HISTORY HISTORY NOW 2010 2008 2015 TESTIMONIALS TESTIMONIALS STORY 1 STORY 1 STORY 2 STORY 2

Medical records

Transcript: Purposes: Culling c) Managerial purpose: Definition -Definition -Purposes -Different forms -Culling systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. 1-documenting communication among patient and health care provider and professionals contributing to the patient's care. 2-to provide data for internal hospital auditing and quality assurance, and to provide data for medical research. 3-financial and accounting purposes the individual medical record may serve as a document to educate medical students/resident physicians. Medical records a)clinical purposes: b) Educational purposes: 1-determine the patient's medical history and provide informed care. 2-The medical record serves as the central repository for planning patient care Different forms a) Clinical purposes. b) Educational purposes. c) Managerial purposes: it's the process of removing the medical records which not been used for a certain number of years. MRO department -Maintenance, repair, and operations-

Medical Records

Transcript: Duties and Responsibilities -Review and record data of patients -Track patient outcomes -Protect patients’ health information for confidentiality -Organize data for clinical databases and registries Aptitudes + Abilities Analytical skills, Detail oriented, Interpersonal skills, and Technical skills. Working Condition: Work in hospitals or physician offices. Most work full time. Salary: $32,350 Annually Outlook: Nationally: 21% Hawaii: 19% Educational + Training Requirements: High School Courses: Health, Computer Science, Math, Biology Post-High School: medical terminology, anatomy and physiology. Training + Special Requirements: Post-secondary certificate and associates degree. Bibliography: "Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 3 Dec. 2012. Engineering Long working hours (-) Pays a lot (+) You won't need to be stuck inside all day (+) May travel to places around the world. (+) Requires a lot of education and studying (+) Photography You get to travel (+) Doesn't pay much (-) You'll get to witness many beautiful sceneries. (+) Medical Records Pays kind of well. (+) You'll be stuck in the office all day. (-) Long term goal: To get a good paying job that I will enjoy and become successful in. Freshman: -English -World History -Geometry -Biology -Japanese 1 -Drawing/ Painting -Into to Business Sophmore: -US history -Algebra 2 -Honor's Chemistry -Health -PE -Japanese 2 -Ceramics Junior: -Modern Hawaiian History -Triganometry -AP Chemistry -Ceramics 2 -Japanese 3 Senior: -SRSS -Pre- Calculus -Senior Project -Japanese 4 Co-Curricular Activities: LEO club After High School: College Conclusion: Out of all the careers I researched, I believe engineering is the job that appeals to me the most. One advantage of pursuing this job is that it pays well. But on disadvantage of this job is that you work long hours. From this project, I learned that there are many job opportunities out there; more than I thought. Which career should i choose? Health Services Pathway Medical Records Duties and Responsibilities 4 Year Plan: By: Isis Harper Period 5 Short-Term Goals

Medical Records

Transcript: What about the patient ? alive ? Contents The medical stuff who dealing with the patient (doctor/nurse...) and the patient himself ( ID info ) Local address Telephone number WHO CAN SEE MEDICAL RECORDS? health record/ medical chart All health records held by hospitals 1- To provide continuity of care. 2- Meeting current legal requirements, including enabling patients to access their records. 3- Assisting in clinical audit. 4- Supporting improvements in clinical effectiveness through research. 5- Providing the necessary factual base for responding to complaints and clinical negligence claims. 6- Decide upon the appropriate course of care and provide rationale. 7- Create context for a patient’s story, and make one patient memorable from the next. 8- Communicate with referring and consulting colleagues Patient's health history * Patient instructions. * Administration of drugs and therapies. * Orders for the administration of drugs and therapies. * Test results. * X-rays. * Reports. Purposes died ? It is a legal document that is written by physicians, nurse practitioners, nurses and other members of the health care team. It includes a variety types of "notes" entered over time, recording observations about the patient Medical Records MEDICAL RECORDS COLOR CODING Access is only allowed to: the patient’s “personal representative” and / or other people who may have a claim arising from the patient’s death. They have a right to see the relevant part of the deceased’s health record. WHAT's UP? Medical examination findings The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite * Lab test results. * Medications prescribed. * Referrals ordered to health care providers outside of the hospital. * Educational materials provided. PRIVACY

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Medical Records

Transcript: Nursing informatics: is endeavor of analyzing, modeling, and formalizing how nurses: IV. Nurse Medical Record III. Patient [Personal] Health Records (PHR) It is a systematic documentation of a patient's individual medical history and care What is a medical record? Time spent on paperwork Missing charts Duplicated tests Created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization. Computer-based Patient Records (CPR) Costs of paper forms Finding charts I. Electronic Medical Records (EMR) Traveling Time Errors Privacy risks ;) Created, gathered, managed, and consulted by authorized clinicians and staff. across more than one health care organization. II. Electronic Health Record (EHR) Electronically maintained information about an individual's lifetime health status and health care Not an object, but a set of systems Fast, secure and accurate documenting Drawn from multiple sources while being managed, shared, and controlled by the individual. Medical Records Paper Medical Records 1. Collect and manage data. 2. Use data to derive information and knowledge. 3. Make decisions and inferences for multidisciplinary patient care. Yousef Alsharhan

Free PowerPoint Templates

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