235 Search Results for Clinical Documentation and the Health Record The
Electronic Medical Records
While history counts the inventor of paper among the hundred most influential people in the history of mankind, the services of paper have proven to be doubtful during floods, earthquakes, fires and other disasters. With t Continue Reading...
Mobile Computing
Research shows that Social media is playing a huge part when it comes to the health care industry. One study done by DC and Interactive Group shows that beyond 90% of individuals from the ages 18-24 mentioned they would rely on heal Continue Reading...
Dental Amalgam: The Risks and Alternatives
Some of the most common dental restorative materials currently in use are dental amalgams, but these compounds contain approximately 50% mercury making their use controversial, particularly with young child Continue Reading...
Nursing Process Improvement and Change
Change management or process improvement in healthcare guarantees that the vital systems in the healthcare organizations are functioning at their optimal. The objectives of healthcare procedure enhancement are Continue Reading...
There needs to be a balance between spending only the money that is necessary while at the same time making sure that all the necessary milestones and performance measures are met.
Going too cheap on such metrics will lead to inopportune shortages Continue Reading...
Organizing Medical Records:
One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced Continue Reading...
Gynecologist
In this presentation, the author will give an overview of the procurement and analysis of medical records required for a patient who needs to see a gynecologist for abnormal uterine bleeding at a gynecological office. This previously wo Continue Reading...
(Andrews, 1985)
The study found that computer charting was well accepted by therapists. "Charge capture was reduced from a four-step manual process to a single-step computer documentation of the procedure. Computer charting was more complete and in Continue Reading...
Best Practice to Isolate MRSA Patients in the Hospital Environment
Methicillin-Resistant Staphylococcus Aureus (MRSA) is an anti-microbial organism of concern in the healthcare field; therefore, preventing and controlling its spread within the heal Continue Reading...
Ethics to Practice: Analysis of 'end of life' decision making
The foregoing discussion is an incursion into nursing ethics. Implication(s) to 'omission' of information as a customary practice within our healthcare institution is reviewed in relation Continue Reading...
Routine Shaving of the Surgical Site
Select a preoperative procedure (e.g., routine shaving of the surgical site) that you would commonly find on a surgical floor.
Describe the process or procedure you have chosen and why you think it needs change. Continue Reading...
Nursing Informatics Field
Definition of informatics nurses
Example of nursing informatics in practice (software applications)
Recent Growth
Nursing shortage and its impact
Need for automated processes over manual processes
Need for increased pa Continue Reading...
In this regard, it is vitally important that leadership communicate effectively with staff, with particular focus on the fact that quality improvement in patient databases means improved quality in health care. This is good not only for patients, bu Continue Reading...
Integrated Patient Managed-Care Information System
Identifying a Cost-Effective Integrated Patient Managed-Care System for Concord Hospital: A Managed-Care White Paper
This white paper is provided in response to a request review integrated patient Continue Reading...
Search the U.S. Department of Health and Human Services National Guideline Clearinghouse website at http://www.guideline.gov / for a quality guideline that pertains to the area of nursing in which you are interested. Describe the guideline and how th Continue Reading...
Training staff members requires additional costs. There is also the 'time' cost of using the system on a daily basis. Furthermore, many find the demands of using the system -- typing into a machine as the patient talks -- to be profoundly impersona Continue Reading...
Medicare and Medicaid Services (CMS) announced in January that ICD- 10-CM will be implemented into the HIPAA mandated code set on Oct. 1, 2013.
Introduction to the new structure of ICD manual o Statistics
The International Classification of Diseas Continue Reading...
Nursing Organization Plan
Nursing Org Plan
The author of this report is asked to lay out a master plan for a nursing/medical organization spoken and enumerated from the standpoint of a new nursing executive. The plan given in this report will have Continue Reading...
Nursing Administration Specialist
Dr. M's dilemma
Strengths
The hospital has a very strong reputation within the community and an over hundred-year history.
The hospital has just been purchased by a university hospital system with an equally stal Continue Reading...
Organizational Leadership and Team Development
Organizational Leadership & Inter-professional Team Development
In a contemporary healthcare environments, application of a quality healthcare is a complex system because it encompasses unique regu Continue Reading...
Electronic medical records have developed to become an important component of today's health care systems because they lie at the center of computerized health information systems. Actually, the lack of electronic medical systems contributes to numer Continue Reading...
Patient Handoffs
Majority of the medical errors take place in the patient's handoffs. A shift among the doctors is a common practice. There are a number of old patients who approach around 16 different doctors in a year, while young patients who are Continue Reading...
Patient Identifiers
The Importance of Patient Identifiers
Adverse events as a consequence of medical treatment are now recognized to be a significant source of morbidity and mortality around the world (World Health Organization [WHO], 2005). Somewh Continue Reading...
Wound Care
Chronic wounds represent a devastating health care problem with significant clinical, physical and social implications. Evidence suggests that consistent, meticulous and skilled care provides the primary means by which successful wound ca Continue Reading...
Role of Staff Education in Pressure Ulcer Incidence in Long-Term Care Residents
Pressure ulcers (PUs), also known as bed sores, decubitus ulcers, or pressure sores, are formed where skin and tissue are squeezed between bone and an outside surface fo Continue Reading...
Evidence-Based Protocol Implementation
Influencing Multiple Systems Through Evidence-Based Change as advance practice nurse, work informed factors direct reach, influence extends context labor. Likewise, propose a nurse leader influenced multiple sy Continue Reading...
More times than not, a patient will argue that he did not understand what the physician stated to him; even amidst documented proof the medical professional and the patient did engage in an informed conversation. "The fact that a meeting took place Continue Reading...
nurses deliver evidence-Based care?
Define main ideas within the title supported from the literature
Nurse instructors confront many hurdles in the present healthcare environment. Educational methods, philosophies, and the content of curricula is Continue Reading...
Employee turnover and customer satisfaction: a comparison of rural and urban healthcare facilities
Staff turnover within the long-term care industry continues to increase at a significant rate (Castle, 2003). National averages show the overall turn Continue Reading...
Impact of Nursing Informatics on Efficiency of Nursing and Improved Patient Outcomes
Although some critics charge that innovations in technology are having a negative effect on humankind, virtually none of them deny the positive effect of such innova Continue Reading...
nursing organizational chart obtained was from this website, http://Hospitals.unm.edu/nursing/.
UNM has a Nursing Division meant to solve and identify the most significant questions concerning human health within the community, through care, servic Continue Reading...
End-of-life care provided by nurses in palliative settings necessitates conscious awareness of several factors that contribute to the effectiveness of care. Factors that are significantly important components of nursing in end-of-life care include co Continue Reading...
Falls
THE ISSUE OF ACCIDENTAL FALLS
At some point, anyone who had learned how to walk has had the experience of falling down -- it is a universal experience for infants as they gain ambulatory ability. In hospitals, however, the accidental fall is Continue Reading...
Release of Information
A Quality Assurance Indicator and Process for Measuring the Accuracy of Release of Information Requests
According to James F. Keenan (1993), questions about the accuracy of releases of information have assumed increasing prom Continue Reading...
Quality Improvement Program
Needs Assessment and Quality Improvement Plan
Paula Stechschulte, PhD, RN
Quarter
This paper discusses the process of drafting a quality improvement plan at a community level medical facility, a plan that is aimed at Continue Reading...
Urinary Catheterization
Urinary catheterisation: indwelling catheters
Urinary catheterization: indwelling catheters
In the medical field, the uses of indwelling catheters have become a common patient care intervention (Clinical Review, 2009). In a Continue Reading...
Standing Orders, Computerized Order Entry, & Admission Pressure Ulcers
Standing orders are non-patient specific orders written by a physician or a nurse practitioner (Primer on standing orders for immunizations and emergency treatment of anaphyl Continue Reading...
The Purpose of E/M Codes
E/M codes are generic and are intended for use by all medical practitioners including nurse-practitioners, physicians and physician assistants. They can be used in both specialty care and primary care. All E/M codes can be u Continue Reading...
The brain while expanding pushes the skull outward in the same perpendicular to the closed structure. This will be marked by the occurrence of 'papilledema' 'pseudoproptosis' as also 'optic atrophy.' (39) This results in the orbital socket being sma Continue Reading...