The Medical Record

The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future.

It is a communication tool that not only provides clinical data regarding a patient’s current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, and to review utilization and quality of care.

The Contents of a Medical Record

* Face sheets, encounters for each visit
* Vital Signs
* Physician’s orders
* History and Physical forms
* List of Medical Problems
* Medication Lists
* Progress Notes
* Discharge Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory Testing
* Operative Reports
* Pathology Reports

Documentation

Documentation is the most critical function regarding keeping accurate medical records, as it records all of the important details and facts regarding a patient’s care.

Documentation:

is legal documentation
includes a patient’s medical history
chronologically documents a patient’s care
allows physicians to plan and evaluate a patient’s care
provides continuity in care
allows all physicians involved in a patient’s care to communicate with each other
provides evidence of care provided in legal cases
assists in claims review and reimbursement
assists in meeting accreditation requirements

Centers for Medicare and Medicaid Services (CMS) regulations regarding documentation

Documentation MUST include:

evidence of a physical examination performed no more than seven days prior to admission or within 48
hours of admission

results from patient consultations and the findings from such evaluations

all orders, progress notes, medication records, radiology procedures and results, laboratory results,
and vital signs

the admitting diagnosis

a patient’s medical complications

any relevant risk factors

information that reflects the CPT/ICD-9 codes that were submitted to the patient’s insurance

consent forms signed by the patient

the discharge summary which summarizes the outcome of the admission, disposition of care, and
plans regarding follow up care

The S.O.A.P. Model

Subjective

Subjective information includes information given directly by the patient, such as how they are feeling, their opinions on their care, and why they made the appointment. It represents the patient’s point of view of their condition.

Objective

Objective information represents the physician’s point of view. It includes information that was observed and measured by the physician during an examination or test.

Assessment

The assessment identifies the main diagnosis that is specific to the visit, and includes the physician’s interpretation of that condition. When a patient has multiple diagnoses, a physician will dictate their assessment based on the patient’s complaint that particular day.

Plan

The “Plan” segment is when a physician makes a plan of action for a diagnosis, usually the condition specific to the visit of that day.

Challenges within Documentation

Every organization should ensure that each page within the medical record contains the patient’s name or identification number (the patients first and last name, first initial and last name, social security number, or personal identifier).

It is also necessary that all entries within the medical record include identification of the author.

Any known drug allergies should be prominently noticeable within the record, preferably on the front of the chart.

If any issues are unresolved from a previous visit, they should be addressed in subsequent visits.

Legibility

The most common challenge within medical documentation is legibility. It is vital that the contents of the medical record are legible to someone other than the author because 1) documentation has a significant impact in resolving legal claims and 2) poor legibility can lead to misunderstandings (i.e. if a pharmacist misreads a prescription and dispenses the wrong drug to a patient).

It is recommended that organizations and physicians utilize transcription services. It is also recommended that organizations and physicians use computers to print orders and prescriptions.

Verbiage

Medical record entries should NOT include any gaps or inappropriate language. This would damage the integrity of the rest of the medical record.

Entries should NOT reflect judgment that something unexpected happened. Words such as “unintentionally”, “inadvertently”, and “unexpectedly” should NOT be used within dictations.

Entries should also NOT use words that are unspecific and cause doubt, especially in the case of a legal claim. Words like “appeared” and “apparently” should NOT be used.

Entries should NOT contain ambiguous words or phrases such as “doing well” or “eating better”.

Claims Reimbursement

Documentation is the best support in proving “medical necessity”. Poor or minimal documentation can lead to the denial of a claim.

Documentation Rules

Correcting Errors

To correct an error within an entry, the author must draw a single line through it so that the original content is still visible. If there error is completely covered or blacked out, it will cause concern and the worst may be assumed of what it may have been. The correct documentation should then be written above the error and should be signed, dated, and the reason for the correction should be noted.

Hearsay

Any statement made by anyone other than the author of the entry, should NOT be documented as if it were fact. The source of the statement should be noted and the statement itself should be in quotation marks.

Telephone Calls

Under no circumstances should medical advice be given over the phone unless it is certain who is on the other end of the call. There should be policies in place that dictate who may give advice over the phone (i.e. nurses, physicians… NOT receptionists) and what the limits are of what type of advice someone other than the physician may provide.

ALL phone conversations should be documented and placed in chronological order within the medical record.

Countersignatures

A countersignature is a signature from a physician who reviews a record after the primary physician has signed it. The countersignature implies that the physician understands and agrees with the care described by the dictating physician.

It is important to acknowledge, that when a provider signs an entry within a medical record, that they are responsible for whatever is contained in the entry.

Abbreviations

Although abbreviations save time, many are ambiguous and can be misinterpreted by other physicians. Only standard abbreviations should be used to avoid any misinterpretation.

Documenting the Termination of a Physician/Patient Relationship

ALL issues of patient non-compliance should be objectively documented within the medical record. Any action taken, reinforcement or education, should also be noted.

When a physician intends to notify the patient of the termination, they should be told verbally. A certified letter should then be sent to the patient outlining the reasons of termination and time frame in which the relationship will terminate. A copy of the certified letter should also be kept within the record.

Record Retention

The length of time in which medical records must be retained differentiates between statute of limitation regulations and individual state statutes.

However, everyone organization MUST enforce clear policies and procedures regarding maintaining and retaining medical records.

Release of Records

Records may only be release as authorized by individual state and federal laws.

Organizations must also have clear policies regarding the release of medical records that should determine:

* who may request and receive a copy of a patient’s medical record
* who is authorized to release medical records and to what parties
* how the practice will protect protected health information
* how releases of records will be monitored and documented

Strong policies on the above greatly assist in avoiding liability.

Ownership of Records

The ownership of medical records is a unique situation, as both the patient and the medical facility have ownership interests. The facility owns the physical record however the patient owns the information within the record.

Therefore, the record MUST remain within the medical facility, and the facility should ensure that the patient’s information is protected.

Patients have the right to any information within their record, however such rights differentiate between states.

Legal

When legal claims arise, medical documentation is relied upon to determine the standard of care that was provided. Little or no documentation regarding the course of treatment strongly supports the claim of negligence.

Medical records may expose:

– the series of events that led to a patient’s injury and subsequent claim

– inefficient use of information within the medical record

– poor communication from on doctor or department to another

– illegible records or orders

iPracticeConsultant.com is a comprehensive website addressing managing a medical facility. iPracticeConsultant focuses on the financial aspects of operating a medical facility, human resources guidelines in managing staff, marketing information specific to healthcare, and healthcare risk management. iPracticeConsultant also provides various financial calculators to allow managers to conduct quick and accurate financial analysis.

 

What Is Medical Tourism? Medical Tourism Facts Explained

Medical tourism is the practice of travelling to different countries to get quality and affordable healthcare services. It is also referred to as global healthcare, health tourism, and medical travel. The term ‘medical tourism’ was created by the media and travel agencies to popularize this form of practice. Today, medical tourism has grown to become an official industry in more than 50 countries.

Why is Medical Tourism Popular?

So, what exactly are the benefits of medical tourism and why do people travel abroad for simple and complex medical procedures? The main factor that encourages medical travel is undoubtedly the high cost of medical care in developed countries like the United States. Most medical travel destinations offer surgeries at almost one-third the costs of developed countries. This translates into bigger savings for a person who has to undergo a complex medical procedure like a liver transplant or even for a cosmetic surgery procedure.

Another reason is the high costs of medical insurance in western countries which have led to many people not opting for any medical plans. The high unemployment rates in the U.S and other European countries are another major contributing factor. Today, due to the deteriorating unemployment levels millions of people can no longer afford health insurance. So, a person not covered by health insurance has very less options other than seeking cheaper treatment elsewhere. As a result, medical travel has gained rapid acceptance and popularity in a short period of time.

Medical Tourism Costs Comparison

Here are some surprising cost comparisons which justify the existence of the medical tourism industry. A liver transplant in the U.S would cost close to a whopping $300,000, while a person who opts to travel to Taiwan would end up paying just around $90,000. This translates into savings of around 70 percent. Similarly, a heart valve replacement costs about $10,000 in India, whereas it costs around $200,000 in the United States. Women who plan to undergo complex cosmetic surgery have to spend a fortune in the U.S. In this case, a full facelift in South Africa would cost just around $1250 compared to about $20,000 in the United States. These glaring price cost savings are the most important reason for the huge growth in the medical tourism industry

Pros and Cons of Medical Tourism

Medical travel abroad isn’t just popular because of the cost savings. There are many other benefits too. For example, the waiting times for medical procedures in the U.K are long and cumbersome. On the other hand, in medical tourism, a patient’s entire procedure is planned and scheduled well in advance. Once the patient arrives in the host country, there is little to no waiting time. Here is another example to illustrate this point. In Canada, during the year 2005, more than 750,000 Canadians had to wait for an average of 9.5 weeks to get their medical procedures done. Canada also sets long waiting benchmarks ranging from 16 to 26 weeks for non-emergency medical procedures like cataract and hip replacement surgery.

While the medical travel industry has its benefits it also has its share of drawbacks and concerns. For example, a medical tourist can easily be susceptible to many diseases in the host country, where high standards of hygiene may not be available. A person from the United States may have low to no natural immunity levels to these diseases. These diseases could hamper or complicate existing health conditions. Some of the diseases that could weaken or complicate the recovery of the person are amoebic dysentery, influenza, typhoid, and tuberculosis. Health complications could also arise during travel due to cramped seats in airlines and long distance flights.

Even accredited hospitals in countries like India lack adequate complaint registering policies. This leads to a lot of patients being totally dissatisfied with the services offered. There are also many legal and ethical issues involved during organ transplantation in India and China. This primarily is due to the large-scale illegal purchase of tissues and organs in these countries. Despite these shortcomings, medical travel seems to be the way forward unless countries like the United States can manage to cut their medical costs drastically or start providing medical tourism insurance.

Popular Medical Tourism Destinations

Many people are on the lookout for both simple and complex procedures like cardiac surgery, hip and knee replacement, dental surgery and cosmetic surgery. For these procedures the most popular medical travel destinations are India, Argentina, Cuba, Hungary, New Zealand, Saudi Arabia, South Africa, The Philippines, Ukraine, Lithuania, and South Korea. High quality cosmetic surgery at affordable prices is available in countries like Argentina, Brazil, Mexico, Costa Rica, Turkey, and Colombia. Over the last few years, South American countries like Brazil, Argentina, Colombia, and Bolivia have become a hot destination for world-class plastic surgeries. These countries boast of talented and experienced cosmetic surgeons of repute. Most medical tourists come from countries like the United States, Canada, the U.K, and Japan.

Implications for the Healthcare Industry

Medical travel has created implications in countries from where they originate. In 2007, more than 750,000 Americans sought healthcare services outside the country and more than 1.5 million are expected to seek offshore healthcare in 2008. This has resulted in the United States health care industry losing billions of dollars and is set to lose even more in the future. According to a Deloitte Consulting report of 2008, medical tourism in the United States could most likely increase by almost 10 times in the next decade. This trend is alarming and can hardly be ignored by the healthcare industry. While this may spell trouble for the healthcare insurance industry, it could also be a motivating factor for the healthcare industry to lower its premiums to stay competitive. This major shift towards medical tourism has opened the doors for medical tourism insurance. Currently, very few medical insurers cover medical tourism. However, there is a growing demand for medical tourism insurance and we might soon see major healthcare insurance providers offering people the option to travel abroad. This would definitely be an important step in making healthcare more affordable.

Monitoring Industry Best Practices

To ensure higher standards of healthcare quality a growing number of international healthcare accreditation organizations are now certifying international hospitals. This accreditation is awarded based on the level of healthcare services and quality of medical procedures provided. Since 1999, the Joint Commission International (JCI), a non-profit organization based in the United States has been authorized to certify and accredit hospitals and medical facilities outside the country. Medical tourism providers in many countries are now seeking accreditation to keep on track with healthcare best practice norms and gain patient confidence and trust.

The medical tourism industry is growing and will continue to rapidly surge unless healthcare providers and insurance companies make sincere efforts to lower the costs of health insurance. Medical travel is not a problem; it is an answer to cheaper medical solutions. And unless the healthcare industry in western countries finds answers to reducing costs, medical tourism will definitely be the most convincing answer.

 

Safe Medications Management At Home

Realizing the importance your medication plays in your treatment will help you get the most benefit from your prescription. It is important to take an active role in your health care by being a participating member of your own health care team. Work with your doctor, nurse, and pharmacist to learn as much as possible about your prescription.

Here are some questions to ask your doctor or pharmacist when you are prescribed a new medication, and suggestions on how to safely manage medications at home.

1. Ask for the name of the medicine, including generic and brand name. This can help avoid prescription mistakes. When your doctor prescribes you a new medication, disclose the names of all the medicines you are currently taking, including all supplements, over-the-counter and prescription medications. State any allergies to any medication.

2. Ask for indications, exactly what is this medication prescribed for.

3. Ask for possible side effects and what to do in case of an adverse reaction.

4. Ask for dose and frequency to be taken.

5. How is the medication to be taken? The most common routes for medication’s administration are orally or by mouth, injection; or topically or locally applied such as creams or eye drops.

6. Are there special instructions while taking this medication such as foods, use of alcohol, other medicines; or activities you should avoid while taking this medicine? Ask about any specifics such as take with food, take on an empty stomach, do not crush or activities to avoid such as driving, use of machinery, swimming or exposure to sunlight.

Is there any written information you can take home? Most pharmacies have information sheets that you can use as an at-home reference.

If a doctor is prescribing a medication that is to be taken multiple times a day ask if it can be substituted for a prescription that is equally as effective but given only once or twice a day, thus reducing chance of forgetting to take the medication and even be more cost effective.

Ask if the medication is available in both generic and brand name, ask the pharmacist the difference between the two and decide based on that information. In many instances is more beneficial to request the generic name versus the brand name.

7. How many refills of the prescription are allowed? Some drugs and medication’s management plans have the option to purchase multiple refills at once, up to three months’ supply, for medications that are to be taken for a long-term or are part of the patient’s permanent treatment plan. Usually this system is more cost-effective for the customer.

Ask the doctor for samples, especially if it’s a medication that will be for short-term use, or if you are doing a trial.

8. What should you do if you miss a dose? What should you do if you accidentally take more than the recommended dose?

9. Ask for alternative’s prescription form that best suits you or your patient’s needs. If your child cannot swallow pills, request the medication on liquid form if available. The same applies for the elderlies or adult patient who has difficulty swallowing.

Do not change the form of any medication without speaking to your pharmacist. Some medications can be crushed, chopped and mixed with apple sauce or juice whereas some medicine is unsuitable in any other than the original form. Always ask before altering a medication’s form. Sustained release pills should not be crushed, and some capsules should not be opened.

During your treatment, you may want to schedule a follow-up visit with your physician in order to monitor your progress. Make sure to report any problems or side effects you are experiencing with your prescription.

Understand the Options for Choosing Diabetes Medications

Do you ever wonder how your physician chooses an appropriate medication for you? Do you feel overwhelmed by the sheer number of available medications? These tips will help you understand the choices that are available. In subsequent articles, there will be more information about each class of medication.

While there are hundreds of medications and combinations of medications available, there are seven different classes of medication. Each class works in a different way. Your physician uses his knowledge about you as well as your specific type of diabetes to first decide if you need any medication, and if so, which class to use. He then chooses a medication from that class. If you require medication from more than one class he may choose to prescribe more than one medication or a combination pill which has two or more medications contained in it. This article will provide a brief overview of the classes of medications and how they work.

1.) The oldest class of medication is the sulfonylureas. Until the mid-1990s, this was the only class of oral medications available. Your body must be able to produce insulin in order for these to be beneficial, as they work by stimulating the beta cells of the pancreas to secrete insulin. Some examples of the first generation of these medications are: Tolbutamide (orinase), Tolinase (tolazamide), and Diabinese (chlorpropamide). Some of the second generation medications are: Glipizide (glucatrol), extended release Glipizide (glucatrol XL), Glyburide (Micronase, Diabeta), Glynase (micronized glyburide), and Glimepiride. These medications are distinguished by how long they last in the body, and whether they are cleared by the kidney or the liver. There are two other drugs in this class: Prandin and Starlix, which can be used before meals because they last for a very short time.

2.) The biguanide class has just one medication, called Metformin. Other names are Fortamet, Glucophage, Gluymetza, and Riomet. This medication works by decreasing glucose production in the liver, and it also causes a small increase in glucose uptake by skeletal muscle. If there are no contraindications, the American Diabetes Association as well as the American college of clinical endocrinologists recommends using this medication first.

3.) In the mid-1990s, the Thiazolidinedione class of medications (also known as glitizones or TZDs) was developed. Their primary mechanism of action is to increase insulin sensitivity, which leads to more glucose being taken up by skeletal muscle. Three medications were developed. The first, Rezulin (troglitazone), was taken off the market because it was suggested to cause liver problems. The second, Avandia (rosiglitazone), was withdrawn from the market in Europe but was allowed under selling restrictions in the US because of an increase in cardiovascular events. The third medication, Actos (pioglitazone) had sales suspended in France and Germany because a study suggested it may increase the risk of bladder cancer.

4.) Drugs that affect the incretin system are divided into two subclasses:

a. The first division is composed of injectable drugs which mimic the effect of natural incretins produced by the body. Medications in this class include Byetta (exenetide), Bydureon (long acting exenatide) Victoza (liraglutide), and Symlin. They work by increasing insulin secretion in response to glucose (sugar), decreasing the rate at which the liver puts out glucose, decreasing appetite, and by slowing the rate the stomach empties. These medications have become quite popular because they can help with weight loss, and have an extremely low incidence of hypoglycemia. However, these medications have been in the news because they have been associated with pancreatitis, and may lead to a slight increase in medullary thyroid cancer.

b. The oral medications in this class work by blocking the enzyme which breaks down the incretins. While the level of natural incretins increases somewhat, these drugs are not as effective as the injectable ones. Medications in this class include Januvia (sitagliptin), Onglyza (saxagliptin), and Tradjenta. They are being observed to watch out for complications similar to the injectable medications. They very rarely cause hypoglycemia and do not cause weight gain. They are all being evaluated for a potential cancer risk.

5.) There are three Alpha Glucosidase Inhibitors: Acarbose (Precose), Miglitol (Glyset), and Voglibose. These work by preventing digestion of carbohydrates in the intestine. By preventing carbohydrates from being converted into simple sugars and absorbed into the blood stream from the intestine, this class of medications can help keep the blood sugar from rising after meals.

6.) The newest class of medications is the SGLT2 inhibitors, which block absorption of glucose by the kidney. By increasing the amount of glucose lost through the urine, and decreasing the amount of sugar absorbed back into the blood stream, blood sugar may be decreased. Because none of these medications has been approved by the FDA, the names of the medications are omitted from this article.

7.) Insulin must be used for people with type I Diabetes and is often needed for those with type 2 Diabetes. There are many types and delivery systems which will be discussed subsequently.

With a thorough understanding of your specific type of diabetes, your physician can wade through all the options to select the best match for you. More detailed information about each drug class will be presented in subsequent articles here, and on my website, diabeticsurvivalkit.com. Please feel free to visit at any time for information about medications, cooking videos featuring diabetic meal and dessert recipes, and current news articles.

Did you know, Naomi Home & Jacksplace have key elves in Santa’s class at the North Pole?!

Given that you realize our little secret, why don’t you excite your children that Xmas and get them a personalized page from Father Xmas?!

For a small donation of just £5, we could tap into our connections at the North Post and obtain a letter delivered from Saint Nick himself, only with time for Xmas! The letter will soon be resolved to your youngster and delivered from the North Pole. The depth Santa contains may shock your little ones, including their title, where they are from, an achievement by your youngster (why they are on Santa’s nice record!), and the surprise they are expecting for.

The reindeers need time for you to transport all of these really specific words from the North Post, therefore to get yours over time for Xmas, get yours by Friday 16th December.  santa letter

All proceeds from Naomi House & Jacksplace’s Page from Santa will help produce short lives glow this Christmas time at our hospices.

Don’t take our word because of it!

“Yesterday my small man got in to find a major red envelope looking forward to him. Addressed to Master Luke and stamped from Santa’s Workshop in the North Rod, his eyes immediately grew wide and he tore to the bag when he can! His eyes illuminated up and his voice was giddy with pleasure as he tried to do you know what Father Xmas could say to him.”

Check out this wonderful website from regional lifestyle and mummy blogger, Lukeosaurus and Me, about our Letter from Santa, presenting a lot of facts and photographs of the page itself! Press here to see the blog.