Is it acceptable to open an antepartum record (or any other note for that matter) the day before the patient’s appointment? I seem to remember reading somewhere it was a big "no!" to do that, but I can’t remember where, and I’m not really finding any documentation to back me up. My nurses want to start the antepartum records the day before the patients appointment (or the morning of) because they feel it will be easier. Any links to documentation would be great! Thanks!
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Tag Archives: record
Coding mother’s record with delivery prior to arrival
I am needing help please with how to code this with the ICD CM codes. The patient delivered in ambulance prior to arrival at the hospital. When the patient arrived at the hospital the provider repaired the patient’s lacerations and delivered the placenta. I know there is a code for encounter for immediate postpartum care. I am not sure do I use this with the ICD 10 CM codes for the lacerations? But when I code the lacerations it is asking that I code outcome of delivery and the weeks of pregnancy. So I am not sure exactly what to code for the mother’s record?
Be Cautious of Abbreviations and Acronyms in the Medical Record
Acronyms and abbreviations are acceptable in the medical record if they are commonly recognized. If a practice uses terminology that is not industry standard, it must maintain a list of the abbreviations with definitions and how they are used, and should submit this documentation anytime an audit is done. Because confusing abbreviations can create problems with […]
AAPC Knowledge Center
Ideal Contents of the Medical Record
Healthcare providers must maintain a complete and accurate medical record for all services they perform. These requirements are generally enforced through licensing, the certification process, or credentialing with insurance carriers. Components commonly found in all medical records make each as unique as the individual to whom it belongs. These components include: Each medical record must […]
AAPC Knowledge Center
storing billing records in Electronic health record
Is there any legislature that states I you cannot store patient billing records in the EHR medical record?
Benefits to Implementing an Electronic Medical Record
One of the most cumbersome tasks in a medical office is the maintenance and storage of paper medical records. This statement rings true in all medical practices rather it be dental, family medicine, specialty practices, or a chiropractic office. But what most practice managers and physicians may not realize is that maintaining a paper medical record is also one of the most costly administrative and clerical tasks in the office.
For years, medical offices have struggled with medical record documentation, as well as filing and retention of literally volumes of paper records. They have been stored in costly medical record storage cabinets and when the volumes of records outgrow the office space, they are purged and sent to off-site storage.
A major benefit of an electronic health record is that record maintenance and storage problems go away. All medical histories, medication lists, chart notes, labs, x-rays, reports, letters, and any other form held in a paper record is either documented directly into the EMR or scanned.
Having patient records available at a few clicks of a mouse or touch screen, can be invaluable. Once a medical practice is trained and comfortable using their EMR, physicians and other care-providers save time, and record documentation is greatly improved. Templates can be setup to mimic individual practice standards, or standard templates can be utilized for the entire practice. For example, a template is setup for sore throat, fever, and congestion. At intake when patient complaints are “ticked” in the EMR, a template pops-up requiring only the fields to be completed that pertain to the specific illness. Obviously, if the complaint is a fall or bee sting, the template would be quite different, but only protocol pertaining to the complaint would be visible.
Perhaps the most attractive benefit of adopting an EMR is the overall cost savings it generates. The EMR virtually eliminates the cost of reams and reams of paper, the off-site printing of forms such as encounters or super bills, in-house printing of schedules, and the zillion copies of insurance cards and scripts. Some practices even decrease their payroll costs by implementing an EMR. Without the paper record there is no backend record maintenance, no finding, filing, or re-filing charts, which equates to less labor requirements.
There are many advantages of the EMR over paper medical records, although currently it is estimated that 70% of medical offices have not yet converted to an EMR. With the financial incentives being offered by the Medicare Program and the addition of the Stimulus Package signed into law by President Obama, the percentage of medical offices adopting an electronic record will rapidly increase in the near future.
Any medical office that has not yet begun thinking about electronic implementation should very seriously start researching EMRs to best fit their practice. Eventually penalties will be assessed to offices not in compliance with electronic health record technology.
Harry E. Selent is President of medicalcharting.com and medicalbillingsoftware.com. Harry is passionate about helping single and small practice doctors implement cost effective electronic medical record software.
When a Patient Requests Access to their Medical Record
Establish policy to handle patient medical record access scenarios, legally. Patients have a right to “request to view” their medical record. This right is conferred by the Standards for Privacy of Individually Identifiable Health Information, known as the HIPAA Privacy Rule of 2001 [45 C.F.R. § 164.524]. Let’s review legal details, so you can best […]
AAPC Knowledge Center
Electronic Medical Record Keeping Helps Medical Providers Provide Quality Care
Medical records are extremely important to the running of any sort of health facility, such as hospitals, doctor offices, or nursing homes. They keep track of the health history of a patient, any new diagnoses, any treatment plan that has been prescribed, medications that a patient takes or has taken in the past, allergies that a patient has, etc. All of this used to be documented on paper. When I was working in a nursing home in 2004, all of our records were paper based. We needed to document everything that we did with our patients.
If we checked on our patient at all, even if we didn’t actively do anything in their room, we needed to document this. This ensures that we aren’t ignoring the needs of our patients. Since patients need to be checked on very regularly, a lot of space can be taken up using paper records. Especially since in most states, physical records need to be a kept for a minimum of seven years. It is also more difficult for healthcare professionals in different locations to read paper records of a certain patient. A lot of copying and faxing is required to accomplish this.
Electronic Medical Records (EMR) allows the healthcare professional to be more organized and allows them to more easily keep up to date about their patient. If there is something in particular that they need to find out about their patient, it is more readily available with EMR technology. They no longer need to sift through useless information in order to read the one piece of information that they need.
In most hospitals, a computer is placed in every patient’s room so that medical errors are reduced. Every time a medication is given or a treatment done, the patient’s name-band needs to be scanned so that it is ensured that they are receiving the right medication with the right dose at the right time by the right route. Having a computer right next to you when you check all of these decreases medical errors in the hospital system. EMR also ensures patient confidentiality. Only the people directly involved with the care of a patient can read that patient’s medical record.
Log ins are password protected so unless a healthcare provider gives someone their password, they can’t get in to check on the status of a patient. EMR is a very good system that is readily becoming more widespread throughout our medical system.
Prime Clinical Systems (http://www.primeclinical.com/) designs and installs EMR systems that are easy to use and easily customized to the individual EMR requirements of individual medical practices and professionals.
When a Patient Requests to Amend their Medical Record
How to fulfill their legal right, legally. Patients have a federal right to “request to amend” their medical record. This right is conferred by the Standards for Privacy of Individually Identifiable Health Information, otherwise known as the HIPAA Privacy Rule of 2001 (45 C.F.R. § 164.526). Let’s review legal details so you can best formulate […]
AAPC Knowledge Center
NJ Electronic Medical Record Mandate
The New Jersey Health Information Exchange Project was presented on behalf in the community of New Jersey. Along with this a grant procedure was also submitted. The grant program and also the project had been aimed at facilitating greater adoption of healthcare details norms as stipulated by HIPAA. It pays specific emphasis to the understanding and adoption of ‘meaningful use’ of patient details in healthcare settings. This initiative is commonly called the New Jersey EMR Mandate.
Now, the New Jersey EMR Mandate is also referred to as the New Jersey Well being Data Technology Extension Center or the NJ-HITEC. This initiative can also be aimed at providing healthcare professionals the significantly needed suggestions after selecting facts technology systems for upgrading their operations towards the electronic format, i.e. storage of patient well being records within the electronic format (EMR).
The NJ-HITEC mandate is aimed at the electronic upgrade of practically 6,000 healthcare providers towards EMR platform from the first, 2 years. To gain this goal, the NJ-HITEC is planning to jobs in collaboration community colleges to make certain greater outreach towards the physicians.
NJ-HITEC is a lot more focused upon doctors who are serving the urban and rural populations deemed much more prone to developing healthcare problems. The mandate seeks to achieve out to the primary-care physicians serving these groups to make sure that at least 85% of all paper-using physicians adopt EMR technologies.
New Jersey has a history of taking the lead in enterprising the adoption of healthcare technologies like EMR. The Region HIE Cooperative Agreement Process is one more assistance obtainable in New Jersey through the American Recovery and Reinvestment Act (2009).
This system represents nearly 15 many years of jobs dedicated at facilitating health facts technologies. The state of New Jersey enacted Well being Information Electronic Details Interchange Act or the HINT Act in 1999 that was officially the very first system inside the US aimed at doing an additional transparent regulatory framework for making electronic submission of healthcare facts standardized. A Commission on Rationalizing Health Care Resources had earlier issued its report in 2008 that produced the roadmap for improving delivery of healthcare services.
New Jersey has also been at the forefront of creation of a lot more community-based Well being Data Exchanges that are aimed improving the health popularity from the state’s residents through better-coordinated healthcare centers. These community-based Well being Information Exchanges or HIEs can also be looked upon as the building blocks for making a more coordinated health-information pattern from the land of New Jersey and eventually throughout the nation. This really is basically mainly because community-based initiatives make sure participation from hospitals, long-term care providers and physicians besides other entities handling patient information.
Despite these noteworthy features, NJ-HITEC acknowledges that outpatient healthcare providers inside nation have not been quite enthusiastic about adopting information technology and thus, greater advice in this regard is needed.
Boone Gomez administers edocscan.com. For more information on NJ Emr Mandate and electronic medical records , visit http://www.edocsan.com