coding week6.docx

1 Discussion Post Name Institutional Affiliation Course Name of Professor Date

2 Preparing daily charts Daily charts: A patient's complete medical history and clinical information are included in their medical chart. Vital signs, medications, treatment schedules, treatment plans, allergies, vaccines, test findings, patient demographics, diagnoses, progress notes, and reports are all included in patient charts. All data in patient records is provided by nurses, lab technicians, doctors, and other healthcare professionals involved in the patient's care. Filling charts: nurses should use the straight-filling numeric method which includes filling the charts using an ascending order according to medical records number. Classifying charts : Active and Inactive records are the two categories that exist. Additionally, there are two main categories: Vital and Important. An active record is one that is frequently accessed, required for present operations, and typically kept close to the user (Bania,2020). Clinical coding, a process that converts descriptions of medical diagnoses or procedures into standardized statistical code, uses a medical categorization. Purging charts: after every five to ten years, active and inactive medical records should be separated according to the retention schedule. Organizing medical records : patients should fill in their medical information in chronological order for easy access. They should start with the oldest medical event to the most current ones such as clinics, laboratory visits, or hospital visits. Selection of medical records: when selecting the EHR system, medical practitioners should access and discuss with colleagues the following important points: match system options to your practice size, consider the health practitioners you have and why they may need HER record, consider your functionality needs, ensure there is clarity about all the costs involved, and look ahead towards transforming to the new HER systems ( Ma,2018).

3 Findings and reports: all the findings and reports of patients should be clearly captured and recorded in the HER systems. Treatment : treatment should be done by qualified medical practitioners according to the sickness the patients are suffering from. The treatment records should also be kept safe for future use. Planning ahead: planning ahead helps medical practitioners to save money lives of many patients.

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4 References Bania, R. K., & Halder, A. (2020). R-Ensembler: A greedy rough set based ensemble attribute selection algorithm with kNN imputation for classification of medical data. Computer methods and programs in biomedicine, 184, 105122. Ma, X., Steensma, D. P., Scott, B. L., Kiselev, P., Sugrue, M. M., & Swern, A. S. (2018). Selection of patients with myelodysplastic syndromes from a large electronic medical records database and a study of the use of disease-modifying therapy in the United States. BMJ open, 8(7), e019955.