How to Conduct a Medical Record Review
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Individuals' Use of Online Medical Records and Technology for Health
ONC Data Brief ■ No. 40 ■ April 2018 Individuals’ use of online medical records and technology for health needs Vaishali Patel, MPH PhD & Christian Johnson, MPH 1 Individuals’ electronic access and use of their health information will be critical towards enabling individuals to better monitor their health as well as manage and coordinate their care. Past efforts sought to provide individuals the capabilities to view, download, and transmit their patient health information. Building on these efforts, the 21st Century Cures Act (Cures Act) includes provisions to improve patients’ access and use of their electronic health information via a single, longitudinal format that is secure and easy to understand.1 The Cures Act also calls for patients to be able to electronically share their information. Online access to medical records, such as through patient portals, enable patients and caregivers to access their health information. Mobile health apps and devices connected to a providers’ electronic health record system using open application programming interfaces (APIs) will also allow individuals to collect, manage, and share their health information. Using the National Cancer Institute’s 2017 Health Information Trends Survey, we report on access and use of online medical records and the use of technology such as smartphones, tablets, and electronic monitoring devices (e.g. Fitbits, blood pressure monitors) for health related needs.2 HIGHLIGHTS As of 2017, 52 percent of individuals have been offered online access to their medical record by a health provider or insurer. Over half of those who were offered online access viewed their record within the past year; this represents 28 percent of individuals nationwide. -
Medical Record Review Guidelines California Department of Health Services Medi-Cal Managed Care Division
Medical Record Review Guidelines California Department of Health Services Medi-Cal Managed Care Division Purpose: Medical Record Survey Guidelines provide standards, directions, instructions, rules, regulations, perimeters, or indicators for the medical record survey, and shall used as a gauge or touchstone for measuring, evaluating, assessing, and making decisions.. Scoring: Survey score is based on a review standard of 10 records per individual provider. Documented evidence found in the hard copy (paper) medical records and/or electronic medical records are used for survey criteria determinations. Full Pass is 100%. Conditional Pass is 80-99%. Not Pass is below 80%. The minimum passing score is 80%. A corrective action plan is required for all medical record criteria deficiencies. Not applicable (“N/A”) applies to any criterion that does not apply to the medical record being reviewed, and must be explained in the comment section. Medical records shall be randomly selected using methodology decided upon by the reviewer. Ten (10) medical records are surveyed for each provider, five (5) adult and/or obstetric records and five (5) pediatric records. For sites with only adult, only obstetric, or only pediatric patient populations, all ten records surveyed will be in only one preventive care service area. Sites where documentation of patient care by all PCPs on site occurs in universally shared medical records shall be reviewed as a “shared” medical record system. Scores calculated on shared medical records apply to each PCP sharing the records. A minimum of ten shared records shall be reviewed for 2-3 PCPs, twenty records for 4-6 PCPs, and thirty records for 7 or more PCPs. -
World Journal of Advanced Research and Reviews
World Journal of Advanced Research and Reviews, 2020, 07(02), 218–226 World Journal of Advanced Research and Reviews e-ISSN: 2581-9615, Cross Ref DOI: 10.30574/wjarr Journal homepage: https://www.wjarr.com (RESEARCH ARTICLE) Implementation and evaluation of telepharmacy during COVID-19 pandemic in an academic medical city in the Kingdom of Saudi Arabia: paving the way for telepharmacy Abdulsalam Ali Asseri *, Mohab Mohamed Manna, Iqbal Mohamed Yasin, Mashael Mohamed Moustafa, Fatmah Mousa Roubie, Salma Moustafa El-Anssasy, Samer Khalaf Baqawie and Mohamed Ahmed Alsaeed Associate Professor Imam Abdulrahman Bin Faisal University; Director of Pharmacy services at King Fahad University Hospital, KSA. Publication history: Received on 07 July 2020; revised on 22 August 2020; accepted on 25 August 2020 Article DOI: https://doi.org/10.30574/wjarr.2020.7.2.0250 Abstract King Fahad University Hospital, a leading public healthcare institution in the Eastern region of KSA, implemented a disruptive innovation of Telepharmacy in pursuit of compliance with the National COVID-19 Response Framework. It emerged and proved to be an essential and critical pillar in suppression and mitigation strategies. Telepharmacy innovation resulted in Pharmacy staffing protection and provided uninterrupted access and care continuum to the pharmaceutical services, both for COVID-19 and Collateral care. This reform-oriented initiative culminated in adopting engineering and administrative controls to design the workflows, practices, and interactions between healthcare providers, patients, and pharmaceutical frontline staff. Pharmaceutical services enhanced its surge capacity (14,618 OPD requests & 10,030 Inpatient orders) and improved capability (41,242 counseling sessions) to address the daunting challenge of complying with the inpatient needs and robust outpatient pharmaceutical consumer services. -
Assessment Module
Assessment Module 1 | Page Assessment May 2017 Table of Contents About this Module/Overview/Objectives……………………………………………...Page 3 Pre-test…………………………………………………………………………………Pages 4-5 Chapter 1……………………………………………………………………………....Pages 6-12 Overview Focused Assessment vs. Comprehensive Assessment Considerations in preparing for a physical exam Geriatric Assessment Nursing Components Considerations in Elderly Residents Chapter 2……………………………………………………………………………...Pages 12-14 Root Cause of Behaviors Physiologic Social Environmental Psychosocial Chapter 3……………………………………………………………………………...Pages 14-16 Risk Assessment Eyes Ears Hemiparesis Paraplegia Where to place the resident in the room Chapter 4……………………………………………………………...………………Pages 16-18 Texas Board of Nursing and Assessments Federal Nursing Facility Regulations F272: Comprehensive Assessments State Nursing Facility Regulations Chapter 5………………………………………………………………………….......Pages 18-19 Resources “This is me” “This is me: My Care Passport” Alternate Communication Boards Pain, Pain Go Away Presentation Appendices……………………………………………………………………………Pages 20-48 2 | Page Assessment May 2017 About this Module: Assessment is a key component of nursing practice, required for planning and the provision of resident and family centered care. Information that is obtained from an accurate assessment serves as the foundation for age-appropriate nursing care, enhancing the residents’ quality of life and independence. The LVN must have a specific set of skills in order to adequately and effectively assess the resident, including: a physical assessment; a functional assessment; and any additional information about the resident that would be used to develop the care plan. This module will provide you with all of the information necessary to ensure adequate assessments are completed for each resident in the facility, meeting the state and federal requirements for resident assessment. Overview: Conditions such as functional impairment and dementia are common in nursing home residents. -
A Study of the Management of Electronic Medical Records in Fijian Hospitals
A Study of the Management of Electronic Medical Records in Fijian Hospitals Swaran S. Ravindra1*& Rohitash Chandra2*& Virallikattur S. Dhenesh1* 1 School of Computing, Information and Mathematical Sciences, University of the South Pacific, Laucala Campus, Fiji 2 Artificial Intelligence and Cybernetics Research Group, Software Foundation, Nausori, Fiji *Authors are in order of contribution. Email addresses: SSR: [email protected] RC: [email protected] VSD: [email protected] Page 1 of 24 Key Words: Australian Agency for International Development (AusAID) – is an Australian agency that manages development and assistance projects internationally. AusAID has recently been absorbed into the Australian Department of Foreign Affairs and Trade [1] . Biomedical Informatics – is the field of science that develops theories, techniques, methods pertaining to the use data, information and knowledge which support and improve biomedical research, human health, and the delivery of healthcare services [2] . Cloud Computing- refers to Information Technology services leased to a person or organization over internet network according to service level requirements. It requires minimal management effort or service provider interaction [3] e-Health- an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered through the Internet and related technologies [4]. Electronic Medical Record (EMR)- An electronic medical record (EMR) is a digital version of a patient’s medical -
Nursing Students' Perspectives on Telenursing in Patient Care After
Clinical Simulation in Nursing (2015) 11, 244-250 www.elsevier.com/locate/ecsn Featured Article Nursing Students’ Perspectives on Telenursing in Patient Care After Simulation Inger Ase Reierson, RN, MNSca,*, Hilde Solli, RN, MNSc, CCNa, Ida Torunn Bjørk, RN, MNSc, Dr.polit.a,b aFaculty of Health and Social Studies, Institute of Health Studies, Telemark University College, 3901 Porsgrunn, Norway bFaculty of Medicine, Institute of Health and Society, Department of Nursing Science, University of Oslo, 0318 Oslo, Norway KEYWORDS Abstract telenursing; Background: This article presents the perspectives of undergraduate nursing students on telenursing simulation; in patient care after simulating three telenursing scenarios using real-time video and audio nursing education; technology. information and Methods: An exploratory design using focus group interviews was performed; data were analyzed us- communication ing qualitative content analysis. technology; Results: Five main categories arose: learning a different nursing role, influence on nursing assessment qualitative content and decision making, reflections on the quality of remote comforting and care, empowering the pa- analysis tient, and ethical and economic reflections. Conclusions: Delivering telenursing care was regarded as important yet complex activity. Telenursing simulation should be integrated into undergraduate nursing education. Cite this article: Reierson, I. A., Solli, H., & Bjørk, I. T. (2015, April). Nursing students’ perspectives on telenursing in patient care after simulation. Clinical Simulation in Nursing, 11(4), 244-250. http://dx.doi.org/ 10.1016/j.ecns.2015.02.003. Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). -
The Electronic Medical Record: Promises and Problems
The Electronic Medical Record: Promises and Problems William R. Hersh Biomedical Information Communication Center, Oregon Health Sciences University, BICC, 3 18 1 S. W. Sam Jackson Park Rd., Portland, OR 97201. Phone: 503-494-4563; Fax: 503-494-4551; E-mail: [email protected] Despite the growth of computer technology in medicine, the form of progress notes, which are written for each most medical encounters are still documented on paper encounter with the patient, whether done daily in the medical records. The electronic medical record has nu- hospital setting or intermittently as an outpatient. Inter- merous documented benefits, yet its use is still sparse. This article describes the state of electronic medical re- spersed among the records of one clinician are those of cords, their advantage over existing paper records, the other clinicians. such as consultants and covering col- problems impeding their implementation, and concerns leagues, as well as test results (i.e., laboratory or x-ray over their security and confidentiality. reports) and administrative data. These various components of the records are often As noted in the introduction to this issue, the provi- maintained in different locations. For example, each sion of medical care is an information-intensive activity. physician’s private office is likely to contain its own re- Yet in an era when most commercial transactions are cords of notes and test results ordered from that office. automated for reasons of efficiency and accuracy, it is Likewise, all of a patient’s hospital records are likely to somewhat ironic that most recording of medical events be kept in a chart at the hospital(s) where care is ren- is still done on paper. -
Cardiovascular Assessment
Cardiovascular Assessment A Home study Course Offered by Nurses Research Publications P.O. Box 480 Hayward CA 94543-0480 Office: 510-888-9070 Fax: 510-537-3434 No unauthorized duplication photocopying of this course is permitted Editor: Nurses Research 1 HOW TO USE THIS COURSE Thank you for choosing Nurses Research Publication home study for your continuing education. This course may be completed as rapidly as you desire. However there is a one-year maximum time limit. If you have downloaded this course from our website you will need to log back on to pay and complete your test. After you submit your test for grading you will be asked to complete a course evaluation and then your certificate of completion will appear on your screen for you to print and keep for your records. Satisfactory completion of the examination requires a passing score of at least 70%. No part of this course may be copied or circulated under copyright law. Instructions: 1. Read the course objectives. 2. Read and study the course. 3. Log back onto our website to pay and take the test. If you have already paid for the course you will be asked to login using the username and password you selected when you registered for the course. 4. When you are satisfied that the answers are correct click grade test. 5. Complete the evaluation. 6. Print your certificate of completion. If you have a procedural question or “nursing” question regarding the materials, call (510) 888-9070 for assistance. Only instructors or our director may answer a nursing question about the test. -
Use of Nursing Diagnosis in CA Nursing Schools
USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS January 2018 Funded by generous support from the California Hospital Association (CHA) Copyright 2018 by HealthImpact. All rights reserved. HealthImpact 663 – 13th Street, Suite 300 Oakland, CA 94612 www.healthimpact.org USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS INTRODUCTION As part of the effort to define the value of nursing, a common language continues to arise as a central issue in understanding, communicating, and carrying out nursing's unique role in identifying and treating patient response to illness. The diagnostic process and evidence-based interventions developed and subsequently implemented by a practice discipline describe its unique contribution, scope of accountability, and value. The specific responsibility registered nurses (RN) have in assessing patient response to health and illness and determining evidence-based etiology is within the realm of nursing’s autonomous scope of practice, and is referred to as nursing diagnosis. It is an essential element of the nursing process and is followed by implementing specific interventions within nursing’s scope of practice, providing evidence that links professional practice to health outcomes. Conducting a comprehensive nursing assessment leading to the accurate identification of nursing diagnoses guides the development of the plan of care and specific interventions to be carried out. Assessing the patient’s response to health and illness encompasses a wide range of potential problems and actual concerns to be addressed, many of which may not arise from the medical diagnosis and provider orders alone, yet can impede recovery and impact health outcomes. Further, it is critically important to communicate those problems, potential vulnerabilities and related plans of care through broadly understood language unique to nursing. -
Health Information Technology
Published for 2020-21 school year. Health Information Technology Primary Career Cluster: Business Management and Technology Course Contact: [email protected] Course Code: C12H34 Introduction to Business & Marketing (C12H26) or Health Science Prerequisite(s): Education (C14H14) Credit: 1 Grade Level: 11-12 Focused Elective This course satisfies one of three credits required for an elective Graduation Requirements: focus when taken in conjunction with other Health Science courses. This course satisfies one out of two required courses to meet the POS Concentrator: Perkins V concentrator definition, when taken in sequence in an approved program of study. Programs of Study and This is the second course in the Health Sciences Administration Sequence: program of study. Aligned Student HOSA: http://www.tennesseehosa.org Organization(s): Teachers are encouraged to use embedded WBL activities such as informational interviewing, job shadowing, and career mentoring. Coordinating Work-Based For information, visit Learning: https://www.tn.gov/content/tn/education/career-and-technical- education/work-based-learning.html Available Student Industry None Certifications: 030, 031, 032, 034, 037, 039, 041, 052, 054, 055, 056, 057, 152, 153, Teacher Endorsement(s): 158, 201, 202, 203, 204, 311, 430, 432, 433, 434, 435, 436, 471, 472, 474, 475, 476, 577, 720, 721, 722, 952, 953, 958 Required Teacher None Certifications/Training: https://www.tn.gov/content/dam/tn/education/ccte/cte/cte_resource Teacher Resources: _health_science.pdf Course Description Health Information Technology is a third-level applied course in the Health Informatics program of study intended to prepare students with an understanding of the changing world of health care information. -
Module 7 – Hospital and Health Record Computer Applications
Module 7 – Hospital and Health Record Computer Applications The purpose of this module is to provide the user with basic and fundamental knowledge of health care information systems in the healthcare environment with emphasis on applications that relate to the use and storage of patient’s health and clinical information. See additional modules including Module 2 which specifically addresses the Patient Master Index application in further detail. In this unit we will: • Discuss information systems and applications in general in the health care facility • Identify the operations within the medical record service that can be computerised • Identify priorities for implementation using a planned information system strategy OBJECTIVES: Upon completion of this unit participants should be able to: 1. Identify general health care applications found in health care facilities 2. identify applications within a medical record department which could be considered for computerisation 3. Discuss the important points relating to a computerised Master Patient Index 4. State the objectives of a computerised admission, discharge and transfer system (ADT) 5. List the daily reports generated by a computerised ADT system 6. Discuss the basic functionality of a data base system as it relates to use in a healthcare facility 7. Discuss advantages and disadvantages of information systems in health facilities in general Key Definitions: • ADT/ATD – a program used in a healthcare facility that contains information about a patient with regard to facility admission (date and location/bed/ward), transfer information if the patient was moved to another location and the date of discharge which may include whether the patient was transferred to another facility, discharged to home or if the patient expired (died). -
Rules and Regulations of Licensed Practical Nurses
RULES OF THE TENNESSEE BOARD OF NURSING CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES TABLE OF CONTENTS 1000-02-.01 Licensure by Examination 1000-02-.09 Schools - Curriculum, Instruction, Evaluation 1000-02-.02 Licensure Without Examination: Interstate 1000-02-.10 Schools - Educational Facilities Endorsement 1000-02-.11 Definitions 1000-02-.03 Biennial Registration (Renewal) 1000-02-.12 Fees 1000-02-.04 Discipline of Licensees, Unauthorized Practice of 1000-02-.13 Unprofessional Conduct and Negligence, Practical Nursing, Civil Penalties, Screening Habits or Other Cause Panels, Subpoenas, Advisory Rulings, Declaratory 1000-02-.14 Standards of Nursing Competence Orders, and Assessment of Costs 1000-02-.15 Scope of Practice 1000-02-.05 Schools - Approval 1000-02-.16 Interstate Nurse Licensure 1000-02-.06 Schools - Philosophy, Purpose, Administration, 1000-02-.17 Free Health Clinic and Volunteer Practice Organization and Finance Requirements 1000-02-.07 Schools - Faculty 1000-02-.18 Advertising 1000-02-.08 Schools - Students 1000-02-.01 LICENSURE BY EXAMINATION. (1) Application - The application form provided by the Board is to be completed in part by the applicant, signed by him, and attested by a notary public. (a) The name as signed by the applicant will be the name carried in the records of the Board. (See 1000-02-03 (3) for name change regulation.) (b) Part of this application is to be completed by an official of the school of practical nursing from which the applicant graduated. (c) The completed application, accompanied by the statutory fee, shall be submitted to the Board. A filing date for the application is set by the Board for each scheduled examination.