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Medical record Flow Chart

Health Information Practicum

Maggie H

on 31 December 2012

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Transcript of Medical record Flow Chart

Patient's Arrival The Medical staff calculates the times of when the patient sits in the waiting room and when they are welcomed in the back. Waiting Room Take vital signs if nurse available Leave Patient in waiting room
if nurse/room is not available Patient to room if doctor is available All patients wait in the waiting room unless its a life & death problem. Nurse Area The nurse takes vitals such as body temperature, pulse rate
(or heart rate), blood pressure, and respiratory rate. patient's post-examination treatment Post-Examination is when the patient is see by the doctor and the doctor does the examination, the treatment and finalized the home health care. Medical Procedures MRI, CT Scan, Biopsy, ultrasound. etc. All of these test can be done to determine what is wrong with
the patient. These are included
in the record A course of action intended to help care for a persons health problems. Medication Medication giving while in the hospital and also for home care is documented in a medical record. Request contact information Confirm data base information is current
(request updates if not) Confirm patient's existence in data base
(request completion of forms if not) Medication required No medication required Medication given from
pharmacy on site Medical Record Flow Chart Unit 9:
HI 165 Health Information Practicum Created By,
Maggie Hord Billing/Insurance While in the health care facility, a member of the billing department comes to speak with you about the bill. Billing Options: Work/Personal Insurance plans Payments Low income insurance from the State Discharge/Home-bound All discharge papers are mandatory in the record After the patient is discharged from the medical facility, the paper record is taking to staff lunch room where the staff/doctors can review and place missed files in record. Yes, prescription prescribed must
be given to Walgreen's Follow up Appointments The doctor need to see the patient again after two weeks of being discharged to make sure they are healing better. Follow up visit required Check schedule and issue
an appointment Patient instructed to call
with status update Patient supplied with doctor's
contact information The Final Steps 1. After the patient is gone, there is about 30 days until the record becomes permanent.

2. A Record staff member sits down with the record and goes over every file to make sure there is nothing missing or misspelled.

3. If the member finds any flaws with the record they call or visit the doctor to clarify the record.

4. If there are no problems with the record, the staff then withdrawals the stables and scans the records into the the computer to make the record electronic and easier to access.
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