• Scope of Practice
    practice, but practically speaking physicians do not usually perform the work of nurses or other technicians like xray specialists. Therefore, in a medical record, you often won't see documentation from a physician regarding vital signs, administration of routine medications, or performance of an...
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  • Employee Records
    personnel file makes sense for access and legal compliance and readiness. (Heathfield S. M., 2012) Types of Employee Records An employer generally maintains several types of personnel files, for business use, for employee confidentiality, for medical privacy, and for legal compliance. There are many...
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  • Confidentiality in Allied Health
    person who made the changes or who viewed the online record. 2. When should the patient be advised of the existence of computerized databases containing medical information about the patient? The patient should be advised once the data is transferred to the computer database. Patient's...
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  • Local and Foreign Studies
    registered professional nurse or physician's assistant is only authorized to dispense pursuant to an order issued in conformity with a standard nurse protocol or job description, not a prescription or an order written on a chart or phoned in by a physician. C. DRUG STORAGE AND RECORD KEEPING 1. All...
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  • Electronic Medical Records
    will give more responsibility to patients for their healthcare and change the patient into a client who makes treatment decisions with their medical providers. • Provides for accuracy of data • Makes patient care safer by giving the provider current, up to date information, including patient...
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  • Clinical Information and Nonclinical Data
    to administer care and/or treatment or to perform surgery and/or other medical procedures. Consultation report: Health record documentation that describes the findings and recommendations of consulting physicians. Data: The dates, numbers, images, symbols, letters, and words that represent basic...
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  • Guideline for Medical Records
    by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. The medical record may include records maintained in an electronic medical / record system, e.g., an electronic system framework that...
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  • Wgu Nut1 Nursing Informatics
    NUT1 Task 1 Western Governors University NUT1 NUT1 Task 1 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...
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  • Records
    state that medical records shall contain documentation of consultation reports. AOA requirements state that, except in emergencies, consultations are required on critically ill patients, patients who are poor surgical risks, and those whose diagnoses are difficult or obscure. The AOA clarifies that...
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  • Healthcare Information
    inflation d. Problems with obtaining and cost of health services xxi. Families who do not receive insurance coverage through employers and do not qualify for Medicaid assistance are finding it difficult or impossible to get medical care. xxii. Public facilities...
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  • Guidance
    of new human and animal drugs,3 and medical devices, this guidance is intended to assist in ensuring confidence in the reliability, quality, and integrity of electronic source data and source documentation (i.e., electronic records). This guidance supersedes the guidance of the same name dated April...
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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...
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  • Legal and Ethical Considerations - Task 1
    documentation must be maintained in the patient’s permanent medical record. Shadow charts are considered designated record sets (DRS), as they contain protected health information, including information that is used to make health care decisions. The HIPAA Standards for Privacy of Individually Identifiable...
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  • Policies and Procedures in HIM
    need to ensure that patients and their authorized representatives are able to view their records within ten days. This requires facilities to establish a Release of Information queue to make sure that the law is followed and individuals have access to their health records in a timely manner. A...
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  • Allied Health
    person who made the changes or who viewed the online record. (H-315.997 Patients' Access to Information Contained in Medical Records) 2. When should the patient be advised of the existence of computerized databases containing medical information about the patient? The patient should be...
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  • Dino
    clinical data initially documented in electronic health records maintained by hospitals and institutions; electronic case report forms (eCRF), which are increasingly being used by clinical study sponsors; electronically generated laboratory reports; electronic medical images from devices; and...
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  • Hippa
    unless it is required or authorized by law and/or the patient for an important purpose. 3. What is the difference between the privacy and the security of health information? The privacy rule of HIPAA protects the privacy of individuals, health information and medical records. In most cases the...
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  • Audits in Healthcare
    record keeping. - Employees should not be authorized to destroy or get rid of any medical records without proper authorization. - Make sure all patients and clients sign a release of information form before giving out any information to anyone else or any other provider. - The provider’s can...
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  • Hcs 335 Mccall Ethics Case Study
    need to be made. If the provider is not immediately available, depending on the type of practice and working relationship the providers have, it is possible to ask another provider to review the medical record and make a decision about the refill. The providers must have agreed to this type of...
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  • PHS Case
    systems can lead to solutions. Only organized systems — as opposed to the very fragmented, disorganized non-systems that make up much of American medicine — only organized systems can implement reimbursement reform, thoroughly disseminate electronic medical records, and establish sophisticated...
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