Assembling Charts Essay Example For Students

Assembling Charts Essay Lab Reports * Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC All hospital discharges including ERE visits 6. Cardiac * Cardiographs results 12-Lead Kegs * Stress Test Results Cardiac categorization results * Venous camp; / or Arterial Duplex results * All other heart related 7. Procedures * Biopsy * Pop reports (oscilloscope, cyclometers, CAB, etc) * Home Health Orders 8. Correspondence * Letters from consulting physicians 9. Medical History (Old Records) 10. Miscellaneous * All procedures got to watch Mrs.. Cathy as she reviewed charts for deficiencies. If any deficiencies are noted a note is put on the chart and the chart is returned to the Hispanic to have all documentation correct or signed, At II oclock we had a staff meeting where all the staff, even those that work from home comes in and we reviewed EVE growth, scores, and what the department needs to be doing in the up coming weeks. After lunch we started reviewing Cads that have been created from past paper charts. The paper charts have been put on CD to help conserve space, and create a more secure source for saving ad storing past medical histories. 1. X. Rays * All x-Rays * Mammogram * CT scans Mrs. * Ultrasound * Nuclear Medicine test results * Pips DEJA scans * Thyroid scans 2. Referrals All documentation for referral of patients to outside providers Communication k Orange Telephone Message / Intake Sheets * Any Provider to patient communication including: i. Letters of Missed appointments / no shows ii. Letters of Patient Termination 4. H APIPA * AY Consents Treatment, Release Of Information camp; Authorization Patient Info Billing * Patient demographics * CAP information * Insurance information including copies Of insurance cards It is important that all documentation such as spelling of the names, addresses of the parents, ND full names of the parent are correct the final submitted document. It is a costly mistake for the parents to have to change this information later after submission. This is where HAIFA polices come into effect and help healthcare personal to maintain administrative, physical and technical safeguards in protect confidentiality and prevent unauthorized access to health information. It was interesting to learn that any if a mother is not married, and the father is not present when signing the application for a birth certificate that he must ay to add his name after the birth certificate has been filed with the NC Birth Certificate Registry. Ms. Boyd has 4 days to submit Birth and Death Certificates to the Combined County Health Department After numerous trips to verify that all the information was correct on the birth certificates, Ms. Boyd took the time to go over all department policies and procedures for the Release of Information. It is the Health Informations professionals responsibility to make sure that private information is not release into the wrong hands. Failure to do so affects departments credibility in reference and security of information, Guidelines for ROI Reviews the Authorization form to ensure: Specific records are requested (general statements such as all mental health Information or all medical records are not HAIFA compliant) Clearly specific reason for the released record Expiration date Youth has initialed and signed Parent/guardian has initialed and signed Witness has signed Reviews request to make sure there is no clinical contraindication Releases information Authorization form and a copy of the response filed in the health record Health