Health Information Management
Personal health records (PHR) assist patients and allow better management of their care. The private health record concept was developed by ensuring consistent, accurate, and easy exchange with other users through health and communication vocabulary standards (Shanholtzer, 2014). It must be standard driven to promote the constantly changing health information technology. The PHRs should support structured data from the patients and be stored in a definite language. It provides a link to quality, productivity, education, and management knowledge base. The information inputted into the system includes screening dates, lab results, and immunization records, in electronic forms.
A patient would want to create and maintain PHR because of its numerous benefits, including promoting patient engagements, encourages family health care and management, among others. Most activities that improve the health condition do at home away from the clinical setting. When patients can track their health over time and have tools and information to manage their health, they shall be more engaged with their health and healthcare. PHRs also promote better healthcare by assisting patients in collecting information from different providers and improving care coordination. Online PHR is useful in case of emergencies or when traveling as the information will be retrieved easily. Having a system for updating and tracking healthcare data can assist the caregivers, including those who provide care to elderly parents, spouses, or young children, to manage their care and coordinate health care quality improvement.
Clinical Documentation
Queries support the ability to assign a code and are initiated through coding or by a professional. Queries are important in supporting the documentation of medical conditions and diagnoses without the corresponding conditions or diagnoses stated. For diagnostic cause and effect relationships in medical conditions, queries are used to get clarity. There are two types of queries verbal and written queries used in the CDI process (Shanholtzer, 2014). When the verbal queries are used, they must be memorized to compromise conversations with the providers concerning reportable procedures documentation. The conversations must not be non-leading, comprise all the suitable clinical indicators and plausible options. Any response by the providers is recorded for subsequent coding. The electronic and written paper queries must be created concisely and citing suitable clinical indicators and identifying the applicable diagnoses that are basic for the provider to respond correctly. Queries must be grammatically correct and legible with all the clinically supported Options that allow the provider to create their alternate response.
The Clinical Documentation Improvement (CDI) improves clinical records to permit and enhance patient outcomes, accurate reimbursements, and data quality. The CDI professional focuses on reviewing the health record to ensure high quality and clear clinical documentation. The ambiguous documentation does not reflect the provider’s intent, repercussions of the clinical scenario, and assigning a code and code assignment accuracy.
The pros of EHR include financial opportunities, time-saving templates, and the patient portal improves accessibility. Through the adoption of the EHR, an organization shall attain financial incentives offered by Medicaid and Medicare. The government’s additional financial incentive is provided when the medical professionals utilize the EHR to documented compliance with the value-based care initiatives, such as the data supporting the PCHM model (Patient-centred Medical Home). The already created templates are one of the cons of EHR. When using the templates, whether for practice encounters with the patients, it shall ensure the staff input accurate information. One way of saving time and promote patient engagement is by activating the EHR system’s patient portal. It allows the patient to input their information at home or the waiting room, eliminating the hospital paperwork. The EHR cons include criminal hackers, developer delays updating the system, and not following the software industry’s best practices. The disadvantages of ENR outweigh its advantages. Doctors are trained to be cautious and prudent concerning the adoption of newer techniques requiring documentation and evidence is a way of doing things to benefit the patients. The biggest point to stress when purchasing an EHR should be not to rush to buy new software as soon as it is released in the market. Most early adopters face crashes and bugs with new software; thus, it is important to wait for the revised and updated versions.
Hospital Coding
Occlusion is the lumen of a tubular body section or completely closing orifice. The orifice is artificially or naturally created. The occlusion procedure aims to close the orifice or the tubular body sections. It comprises both the extraluminal and intraluminal methods of completing a body section. By dividing the orifice before closing, it is the main part of the occlusion procedure. The occlusion root operations are the same as Restrictions, with the major difference being the ultimate closure instead of partial closure. Occlusion procedures are used for various procedures, including fallopian tube and the inferior vena cava ligation.
Illustration
A patient in the 10th week of pregnancy experienced severe vaginal bleeding and cramping. At the hospital, she was diagnosed with incomplete spontaneous abortion. She was rushed to the operating room, where dilation and curettage were done to remove the conceptions’ retain materials. In ICD-9-CM, the Alphabetic Index’s main term is dilation and while the subterms are curettage and uterus. After the procedure, abortion is identified 69.02 code whose descriptor is curettage whether the procedure used scope or not.
In ICD-10-PCS, after an incomplete spontaneous abortion, the curettage and dilation are coded to Extractions in the Obstetrics section. 10D17ZZ code with a 4th character is used to capture the other extracted products of conceptions. The code ICD-10-PCS differentiates if the procedure was done with scope or not. The fifth character is 7 when conducted without a scope, while 8 is when the scope is used.
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References
Shanholtzer, M. B. (2014). Integrated Electronic Health Records. McGraw-Hill Higher Education.