Briefly discuss the flow of inpatient records from admission to discharge
admission to discharge. 24. Describe the format of the source oriented record 25. Discuss two secondary purposes of the patient record
Discuss the ways that an Admission, Discharge, Transfer (ADT) system could improve quality of care (improving the patient experience; improving the health of populations; and reducing the cost of care). From the perspective of a healthcare IT administrator, how could this technology improve the way that an organization leverages HIT?
1. Inpatient admission: The patient was admitted with possible pyelonephritis; Her complaints were bilateral flank pain and chills. A contrast intravenous pyelogram was normal. Within two days of admission, the character of her pain changed somewhat in that it became primarily in the right upper quadrant. The physician documented in the progress notes that significant features of conversion hysteria were present and accounted for the patient's symptoms. On the third hospital day, the patient's IV was discontinued, lover function tests...
Inpatient admission: The patient, an obese male, was admitted with generalized abdominal pain suggestive of early appendiciis, although he had a normal white count and normal differential. An intravenous pyelogram and X-ray of the lower gastrointestinal tract with barium enema were negative. All laboratory studies were normal. He improved while in the hospital without a definite cause for his pain ever being identified. He was placed on a low-fat, 1,500-calorie diet prior to discharge. Discharge diagnoses: (1) Abdominal pain of...
Dr. Rex Harrison is requesting the medical records of Martha Flynn. He states he is a family friend and has been asked by Mrs. Flynn’s son to review her last inpatient admission for appropriateness of care. Should you release the records to Dr. Harrison
1.Inpatient admission: The patient has a known diagnosis of prostatic cancer. He started having fevers approximately one week earlier. The fevers did not respond to outpatient antibiotics. Blood and urine cultures showed no growth. He was admitted for workup of the fevers with possible prostatic abscess formation. There were no obvious signs of infection or abscess on a transrectal ultrasound of the prostate. An iodine-123 radioisotope bone scan of the body revealed no skeletal metastases. The antibiotic therapy was changed,...
I need #4,5 7, 9 10 4. INPATIENT HOSPITAL Gender: M Age: 42 Reason for admission: Shortness of breath, general- ized weakness, agitation, elevated BP, fever, rapid pulse, history of hyperthyroidism Assessment: Cardiomyopathy due to thyrotoxicosis with thyroid storm Plan: Inhibit thyroid hormone synthesis with Methimazole. Beta blockers, body cooling, FU with cardiologist for cardiomyopathy management 2 ICD-10-CM Codes 5. INPATIENT HOSPITAL Gender: F Age: 26 Reason for admission: Feet and ankle edema, chest pain, shortness of breath, fever Assessment:...
4. INPATIENT HOSPITAL Gender: M Age: 45 Reason for admission: Admitted from emergency department due to skull fracture. He was unconscious for 90 minutes, but returned to his normal state of consciousness. Assessment: Open occipital condylar fracture (type 1) of base of skull with subarachnoid hemorrhage. (continued) 4. (continued) Plan: Craniotomy performed based on CT results which showed bleeding. Vessel occlusion performed. Patient in ICU following surg. RTO 4 days post discharge and weekly thereafter for two weeks. Tip: A...
5. INPATIENT HOSPITAL Gender: M Age: 21 Reason for admission: Knife stab wounds to the chest after a gang fight in a public park Discharge diagnosis: Intrathoracic wound with laceration of right lung. Tip: External cause codes for activity and status are not needed. 3 ICD-10-CM Codes 6. INPATIENT HOSPITAL Gender: M Age: 22 Reason for admission: Admitted from ED. Patient was riding his bicycle for recreation through a parking lot and was hit by a bus. He impacted the...
Select one of the following: Inpatient Records Outpatient Records Physician Office Records Based upon your own practice setting, or your desired practice setting, discuss the key components of the patient record. What makes a thorough and high-quality patient record in your setting?