SU_HCM1201_W3_Project_Wallace_C.doc.
docx
keyboard_arrow_up
School
Independence University *
*We aren’t endorsed by this school
Course
1201
Subject
Health Science
Date
Jan 9, 2024
Type
docx
Pages
6
Uploaded by Lessw22
Celess Wallace
August 14, 2023
Dr Racca
HCM 1201
Week 3 Project
A medical record is a comprehensive and organized document that contains important
information related to a patient’s health and medical history. It serves as a crucial tool for
healthcare providers to track and manage a patient’s health over time. Medical records can be
both physical documents and electronic records stored in a computerized system.
1.
Patient Information: Includes the patient’s name, contact information. Gender, date of
birth and other details
2.
Medical History: This section covers the patients’ past medical conditions,
hospitalization, chronic illnesses, and surgeries.
3.
Medication and Allergies: Details about the medications that the patient is currently
taking which includes frequencies and dosages that are recorded. Any known
allergies or reactions to specific substances and medications are also documented.
4.
Vital Signs: Information about the patients’ vital signs such as heart rate, blood
pressure, temperature is recorded during different medical encounters.
5.
Doctors Notes: These are records of healthcare providers observations,
recommendations, and assessments during each visit. These notes can include
treatment plans, diagnosis, and other findings.
6.
Laboratory and Diagnosis Test Results: Results from various tests such as X rays,
MRIs and blood tests are included. These tests can help monitor the patient’s health
and track changes.
7.
Immunization Records: Documentation of the patient’s immunizations including,
dates and typed of vaccines received is vital for maintaining accurate vaccinations
histories.
8.
Progress Notes: Healthcare providers update these notes during each patient visit4w,
detailing the patient’s progress, any changes in health status and responses to
treatments.
9.
Surgical and Procedural History: If the patient has undergone surgeries or medical
procedures, dates, details, and outcomes of these interventions are recorded.
10. Consultation Notes: If the patient has seen a specialist or received consultation from
other healthcare professionals, these notes are often included to provide a complete
picture of the patient’s care.
11. Discharge Summaries: These are documents produced when a patient is discharged
from a hospital or a medical facility, summarizing the care provided during the
hospital stay and outline any follow up instructions for care.
12. Billing and Insurance Information: Records of medical charges, insurance claims and
payment details may also be part of the medical record.
13. Consent Forms: Any signed consent forms related to procedures and treatments
sharing of medical information are typically included in the record.
14. Advance Directives: Documentation of the patient’s preferences regarding medical
treatments in case of incapacitation, such as do not resuscitate (DNR) orders or living
wills.
It is important to note that medical records are confidential documents protected by
patient privacy laws, such as the Health Insurance Portability and Accountably Act
(HIPPA) in the United States. Access to medical records is typically restricted to
authorized healthcare providers involved in the patents care and in some cases, the patient
themselves.
SOAP notes are a structured format commonly used by healthcare professionals to
document patient encounters, treatment plans and assessments in medical records. The
acronym SOAP stands for Subjective, Objective, Assessment and Plan. Each section
serves a specific purpose in documenting the patient’s condition and the healthcare
providers actions and decisions.
1.
Subjective (S): This section captures the subjective information provided by the
patient. It includes the patient’s own description of their symptoms, concerns and how
they are feeling now. This is the patient’s perspective on their health and is often
recorded in the patient’s own words.
2.
Objective (O): This section, the healthcare provider records objective measurable data
obtained through examination, observation, and diagnostic tests. This includes
physical exam findings, lab tests and imaging studies. The objective section should
provide an unbiased and clinical view of the patient’s health status.
3.
Assessment (A): The healthcare provider summarizes their assessment or diagnosis
based on the subjective and objective information gathered. This is where the
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
provider interprets the data, identifies potential causes of the patient’s symptoms, and
makes a preliminary or definitive diagnosis. This assessment provides a medical
professionals perspective on the patients’ conditions and can involve hypothesis about
underlying issues.
4.
Plan (P): In the plan section the healthcare provider outlines the proposed course of
action for managing the patient’s condition. This includes treatment options,
medications procedures, referrals to specialists and any other steps that will be taken
to address the patients’ health concerns.
When the SOAP note structure is followed, healthcare professionals ensure that each
patient encounters is thoroughly documented and organized. SOAP notes provide a consistent
way for different healthcare providers to understand the patient’s history, status, and ongoing
treatments. SOAP notes can also be used for billing purposes as they provide a clear record of the
services provided to the patient. SOAP notes facilitate effective communication among
healthcare team members ensuring that everyone involved in the patients’ care is on the same
page. SOAP notes is a widely used format, some healthcare settings and electronic health records
systems may use variations pf the format or different documentation framework.
Operative reports play a crucial role in medical necessity coding by providing detailed
documentation of surgical procedures and intervention performed on a patient. Medical necessity
coding is the process of assigning appropriate diagnostic and procedural codes to medical
services and procedures to ensure that they are medically necessary and justified based on the
patient’s condition. This coding is important for accurate billing, reimbursement, and compliance
with insurance regulations. Operative reports are essential in medical necessity coding because they [roved the
necessary documentation to validate the medical necessity of surgical procedures. Proper
documentation ensures that the services provided are supported by clinical rationale, algin with
appropriate codes and meet the requirements of insurance payers and regulatory bodies.
National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
are terms used in the context of Medicare, the U.S. government health insurance program for
individuals aged 65 and older as well as certain younger individuals with disabilities. NCDs and
LCDs help define what medical services procedures and items are covered by Medicare and
under what conditions. These determinations are made by the Centers for Medicare and
Medicaid Services (CMS) to ensure consistent and appropriate coverage for beneficiaries while
managing costs. (Heindel, Smith, Cruz, & Pappas, 2017)
NCDs are decisions made by CMS at the national level regarding whether a specific
medical service, procedure, test, or item is considered medically necessary and eligible for
coverage infer Medicare. NCDs provide guidelines for coverage that apply to all Medicare
beneficiaries across the world. These determinations are typically based on clinical evidence.
Medical literature and expert opinions. NCDs outline the criteria that must be met for a service to
be covered including specific diagnosis patient characteristics and other relevant factors.
LCDs are decisions made by Medicare Administrative Contractors (MACs) at the local
level. MACs are organizations that process claims and administer Medicare in specific
geographic areas. LCDs provide more specific coverage guidance tailored to the needs of a
particular region or jurisdiction. While NCDS provides nationwide coverage rules, LCDS
addresses local nuances and variations in medical practice.
(Medicare Program; Revised Process for
Making Medicare National Coverage Determinations, n.d.)
NCDs and LCDs are mechanisms used by CMS to determine what medical services and
procedures are covered by Medicare and under what circumstances. NCD are broad, nationwide
decisions that apply to all beneficiaries, while LCDS are region specific determinations that
provide additional guidance based on local medical practice. It’s important for healthcare
providers and beneficiaries to be aware of these coverage determinations to ensure that services
are appropriately billed and reimbursed by Medicare.
(Baselski, Weissfeld, & Sorrell, 2004)
References:
Baselski, V. S., Weissfeld, A. S., & Sorrell, F. (2004). Rules and Regulations in Reimbursement
. Retrieved 8 14, 2023, from https://asmscience.org/content/book/10.1128/9781555817282.chap38
Heindel, G., Smith, J., Cruz, J., & Pappas, A. (2017). Utilizing a drug information center for submitting reconsiderations for local coverage determinations. American Journal of Health-system Pharmacy, 74
(3), 106-107. Retrieved 8 14, 2023, from https://academic.oup.com/ajhp/article/74/3/106/5103328
Medicare Program; Revised Process for Making Medicare National Coverage Determinations
. (n.d.). Retrieved 8 14, 2023, from CMS/HHS: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help