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Medical Records
Medical records are legal, written records concerning a patient's medical history, psychiatric history, chief complaint, symptoms, assessment and testing, diagnoses, symptoms, treatments and procedures, medications, and outcomes or responses. All medical professionals are required to document information in their patients' medical records. This category includes the common medical and legal forms patients must complete, what information might be written into a patient's record, how to obtain a copy of your patient record, and how to correct errors in your medical or mental health record.
962 Questions
What example of how incorrect inpatient coding would financially affect a hospital?
Putting the wrong principal diagnosis, such as pneumonia over asthma exacerbation could mean the difference of 5k. Putting the wrong procedure could easily change the DRG by 50k.
my periods are quite irregular, so when I missed my period I thought it was normal. since my husband and I have been trying to have a baby, I took 2 pregnancy tests just to make sure.....they were all negative. At the time I took the pregnancy test, I was 5-6 days late. My advice to you is (through my own expirience), wait another week and do another pregnancy test coz that's what I did and my test was POSITIVE!!! I am now into my 7th week...
Best of luck :-)
What is the medical abbreviation that looks like a division symbol?
The division symbol is sometimes used in writing a prescription. For instance, a daily dose of 1000 mg of erythromycin divided in three doses might be written 1000 mg (division sign) tid.
Why do general practitioners need to update patients records?
As time goes by, the medical profession is always kept abreast of improvements in medicine and medical technology, drugs that have been discontinued and drugs that are new to the market. This is all par of keeping the patient informed. They can only do this when you visit and after that office visit they will update your medical records so that they have the latest pertinent information on all your health needs in case of an emergency.
Can expunged hospital medical records be found?
Most medical records are kept on computers, so they probably could be found if someone knows where to look for them; however, there are strict laws that govern giving out any medical information. Written permission from the person is needed in order to give out that information to third parties. The exception to that is law enforcement agencies can access medical records without a warrant under certain conditions.
What does the medical abbreviation Hx mean?
Hx is an abbreviation for history.
Hx means medical history on documents such as discharge papers and shot records.
Is there a central database of patient history that all doctors can see?
I think it's a priviledged communication between a doctor and a patient. It will be confined to hospital records only. Hope it helps.
Can your doctor hand the patient his own medical records when moving?
Absolutely. The patient is entitled to see all parts of their records except for psychotherapy notes. And the doctor is wise to release those records to the patient when they move their practice -- it saves everyone time in responding to requests for records from the new doc.
What do I need to do to access my mother's medical records and speak to her doctor?
Speaking to your mother's doctor is done the same way as speaking to any other doctor; you make an appointment. If it is necessary to access your mother's medical records, her doctor has access to them and can access them for you. Of course, you will have to have a legitimate reason to have access to her records. I don't know what your reason is. If you are planning a malpractice suit against your mother's doctor, then the courts can subpoena the records.
How can one obtain medical records from 1959 or 1960 regarding a miscarriage?
You can't obtain medical records from 50+ years ago. They have typically been destroyed.
How to obtain my child's medical records of premature birth for March 17 1981 to April 14 1981.?
It's not likely that records were kept from 30+ years ago. Talk to your health care provider or attorney for information specific to your situation.
History and physical may be abbreviated "H&P" on a medical record. In a soap note, you might instead see "HPI" for history of present illness, "PFMSH" for previous family, medical, and social history, and "PE" for physical exam.
What does it mean to have Low levels of lipase?
Lipase is the enzyme that digests fats and oils (lipids). Low levels of lipase means the body cannot digest lipids. The affected person is most probably underweight, and cannot put on weight easily. Other symptoms are smelly & floating stools and gas.
How do you remove that continuing noise in my ears?
if there is a ringing in your ears it might be tinnitus. You cant get rid of it
How did my caridologist see 2 major heart attacks by reviewing my results of cardiac catherization?
A good question for your doctor. However, probably found two areas of blockage. This combined with a seeing two areas of damage to the heart muscle could cause this conclusion.
What is wound care center management?
Wound care center management has to do with the oversight and administering of policies and procedures for a wound care center (a medical clinic or hospital department that uses hyperbaric medicine or oxygen to heal non-healing wounds). Wound care centers are often outpatient facilities (like emergency centers), either attached to a hospital, or simply affiliated with a hospital or set of hospitals but located at some separate physical location to make it more accessible to the community.
Wound care center managers are responsible for patient flow, healing rates, and the fiscal strength of the center. Because wound care is in high demand today, many hospital executives are looking into adding wound care units to their hospitals. There is a proven opportunity for financial gain.
The problem with wound care center management:
Wound care is difficult to administer, and the cost of developing and running a wound care center is very high. Because of the level of difficulty involved in running a wound care center, and because of consistently changing legal policies, hospitals turn to wound care center management companies to help run and manage their wound care units. These companies specialize in the administering of hyperbaric medicine, as well as dealing with compliance issues that arise due to the revolving door of laws that come into and out of existence from Washington and local law makers. Because wound care center management is so specialized, many wound care center management companies have developed profit models that give the lion's share of net revenues to the management company as opposed to the hospital.
Some wound care management companies have been known to develop an environment of dependence - where the wound center managers hire the personnel and staff, purchase and own all of the equipment, and design management models that, in essence, hold the hospital hostage. This happens because hospitals can rarely foot the bill for hyperbaric equipment and when a center is established in a community it becomes a valuable asset to its residents. This gives the hospital very little wiggle room. If the hospital hires a new wound care center management company, the hospital risks losing the center's trained personnel as well as all or most of its hyperbaric equipment - a very cost prohibitive decision to make. If the hospital chooses to close its center, it dissolves an extremely valuable service to its local community.
Today, some wound care management companies are combating this approach by implementing a model that allows hospitals to essentially own their centers. Wound Care Advantage, a wound care center management company out of Sierra Madre, CA, for example, has developed a management model that puts hospitals in the driver's seat, so to speak. Under the Wound Care Advantage model, wound care center employees are employed by the hospital, not the wound care management company. That way, if the hospital should ever need to switch management companies, it can do so easily. Similarly, this company will assist hospitals in purchasing the necessary hyperbaric equipment. They will help hospitals choose the best and most cost-effective solutions, or they will finance the hospitals and allow them to pay back the debt over the course of the contract. This model has been largely embraced by hospitals over the last 10 years.
As you can see, not every wound care center management company is created equal, and hospitals should do ample research before making a partnership decision.
What does universal first aid mean?
It is first aid that is the same throughout the world.
Cyberchief
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Can doctors use abbreviations in medical records?
I think what is meant here is: "Is is permissible for doctors to use abbreviations in medical records?" The answer is, apparently yes, because they do so all the time.
Medical records can easily be used interchangeably with Health records. These records systematically document a patient's history, from medical to demographic. These records are so detailed that they give you a complete analysis of what is patient's current illness, what is his current medication, what were his past medication and illness details etc. Healthcare providers are responsible for maintaining these records for their patients.
Conventionally all the medical records were documented on paper. However, with the advent of Electronic Medical Records these records are now documented electronically using computers. Some established electronic medical records also provide cloud technology, which ensures safety, accuracy, and accountability of medical records.
