• Scope of Practice
    All medical doctors require a license to practice medicine, and this allows them to perform all of the skills I mentioned in the previous paragraph. Because of their extensive training and licensing, physicians have the broadest scope of practice in the hospital. There are few limitations on their practice...
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  • Confidentiality in Allied Health
    proper documentation purposes and to protect the integrity of the data. If ever the patient asks information on whom and when the correction was made, the information will be readily available. It should also include the name of the person who made the changes or who viewed the online record. 2. When...
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  • Employee Records
    there's information that you voluntary choose to keep. You may be legally required to keep certain employee information separately. Specific employee records are what you must retain under federal laws. The information that you keep depends on what the information is and which law covers the retention of...
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  • Electronic Medical Records
    1. Paper medical records still have a place in healthcare, but the complexities of healthcare, its information and the numbers of providers that treat one patient are becoming unmanageable by paper files. Discuss the strengths and weaknesses of paper medical records? The strengths include; • A...
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  • Clinical Information and Nonclinical Data
    Advance directive: A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preference. American Recovery and Reinvestment Act (ARRA):An...
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  • Guideline for Medical Records
    Legal Medical Record Standards Policy No. 9420 LEGAL MEDICAL RECORD STANDARDS PURPOSE To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in federal and State laws and regulations, and to define the portion...
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  • Confidentiality in Allied Health
    Yes, According to the “American Medical Association” medical records should be date and time stamped and identifying the corrector or the person that makes any changes of any sort. This is for proper documentation purposes and to protect the integrity of the data. If ever the patient asks information...
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  • Wgu Nut1 Nursing Informatics
    What is EMR? Electronic Medical Records “a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1) Benefits of EMR * Paper records can be reduced or completely...
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  • Legal and Ethical Considerations - Task 1
    Ethical Considerations – Task 1 A shadow chart is a partial copy of a patient’s medical history, kept by health care providers or departments for the sake of convenience. A shadow chart is not part of the official medical record. It is a working document where information can be added and removed as necessary...
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  • Records
    of the Patient Record: Inpatient, Outpatient, and Physician Office Chapter Outline Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Forms Control and...
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  • Hippa
    security number, diagnosis, test, treatment, doctors or medical provider who provided services to the patient, the insurance company or the health card number and claim information. This information cannot be released unless it is required or authorized by law and/or the patient for an important purpose...
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  • Policies and Procedures in HIM
    required under HIPAA’s Privacy Rule. One critical policy is determining how much of the record the outside transcriptionists are allowed to view in order to perform the transcription task. Limiting their viewing of the record to only critical portions (like only allowing them to view encounter number, date...
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  • Allied Health
    proper documentation purposes and to protect the integrity of the data. If ever the patient asks information on whom and when the correction was made, the information will be readily available. It should also include the name of the person who made the changes or who viewed the online record. (H-315...
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  • Audits in Healthcare
     Audits in Health Care Medical Billing and Coding Piah Miaton Aunquoe 03-30-14 Health care involves a lot of complex and descriptive work in order to keep everything in order and on track. Whenever a patient comes...
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  • Local and Foreign Studies
    TABLE OF CONTENTS DRUG DISPENSING PROCEDURE The Drug Dispensing Procedure Signature Page A. Definitions B. General Requirements C. Drug Storage and Record Keeping D. Outdated, Deteriorated, Returned and Recalled Drugs E. Inventory F. Labeling and Appropriate Containers G. Client Counseling Components...
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  • Dino
    Guidance for Industry Electronic Source Documentation in Clinical Investigations DRAFT GUIDANCE This guidance document is being distributed for comment purposes only. Comments and suggestions regarding this draft document should be submitted within 90 days of publication in the Federal Register...
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  • The Feeding Tube
    * The patient has the right to make decisions about the plan of care before and during treatment. The patient has the right to refuse a recommended treatment or plan of care to the extent allowed by law and hospital policy and to be informed of the medical consequences of this action. In case of...
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  • PHS Case
    health care in 2009 reached nearly $2.4 trillion (expected to reach $2.7 trillion in 2010).1 Despite this vaunting national level of expenditure on medical treatment, death rates due to preventable errors in the delivery of health services rose to approximately 98,000 deaths in 2009.2 To address the...
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  • Hcs 335 Mccall Ethics Case Study
    HCS 335 June 01, 2013 McCall Ethics Case Study Jerry McCall is Dr. Williams’s office assistant. He has received professional training as both a medical assistant and an LPN. He is handling all the phone calls while the receptionist is at lunch. A patient calls and says he must have a prescription...
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  • Health Informatics
    One of the primary inventions of clinical medicine is the patient medical record. Practitioners use the record to capture their findings and conclusions for each clinical encounter and to guide future care of the patient. As medical care gets more and more complex and new information is already overwhelming...
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