Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

Download or read book Electronic Health Record written by Pradeep K. Sinha and published by John Wiley & Sons. This book was released on 2012-11-27 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved. This book on Electronic Health Record: Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others Provides assessment of existing standards Includes a glossary of frequently used terms in the area of EHR Contains numerous diagrams and illustrations to facilitate comprehension Discusses security and reliability of data

Download or read book Documentation Survival Handbook for Psychiatrists and Other Mental Health Professionals written by Stephen Michael Soreff and published by Seattle ; Toronto : Hogrefe & Huber Publishers. This book was released on 1993 with total page 568 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book The Electronic Health Record for the Physician s Office for SimChart for the Medical Office E Book written by Amy DeVore and published by Elsevier Health Sciences. This book was released on 2015-11-12 with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Electronic Health Record for the Physician's Office for SimChart for the Medical Office - E-Book

Download or read book Closing the Chart written by Steven D. Hsi and published by UNM Press. This book was released on 2004-04-30 with total page 226 pages. Available in PDF, EPUB and Kindle. Book excerpt: Dr. Steven D. Hsi, a family physician and father of two young sons, was diagnosed in 1995 with a rare coronary disease that caused his death five years later at the age of forty-four. Throughout his ordeals as a patient, including three open-heart surgeries, Dr. Hsi's outlook on the teaching and practice of medicine changed. In 1997 he began a journal intended for publication after his death. Written with the assistance of newspaper columnist Jim Belshaw and completed posthumously by Hsi's widow, Beth Corbin-Hsi, Dr. Hsi's writings urge his colleagues to become healers, to look at their patients as human beings with spiritual as well as physical lives. "Every patient should read it, if only to be made aware that they are not alone with their thoughts. Every spouse of a patient should read it. . . . Every medical student and physician should read it to learn that the biology of the disease is really just a small part of the illness."--John Saiki, M.D., Medical Oncology, University of New Mexico "Dr. Steven Hsi asks his fellow doctors to be more than physicians. He asks them to be healers. He says that when he thinks of healers, he sees traditional medicine men, people who are integral parts of their communities. They are in touch physically and spiritually with the people they serve."--Tony Hillerman "Closing the Chart is built on the personal journals and experiences of Steven D. Hsi, M.D., as he travels on an intense 5-year journey from an assumption of health, professional success, and family stability to his progressive illness and eventual death. . . . Closing the Chart is both an engaging, page-turning read and a story told with so little artifice that you cannot close the cover unchanged."--Kenneth Jacobson, executive director, American Holistic Medical Association, Explore “There are lessons on every page, lessons to make us better caregivers, more discerning patients, and better advocates for family members and friends who are sick. . . . Every reader will take away different lessons from this book based on his or her role, age, and experience. This would be an ideal book for group study by medical and nursing students with some senior physicians, patients, and family members. What a great learning experience for all participants! . . . I exhort you to pick up and read this humble story. Nothing I have encountered in the medical narrative genre has been more worthy of my time.” —David J. Elpern, M.D, Psychiatric Services

Download or read book Our Bodies Our Data written by Adam Tanner and published by Beacon Press. This book was released on 2017-01-10 with total page 226 pages. Available in PDF, EPUB and Kindle. Book excerpt: How the hidden trade in our sensitive medical information became a multibillion-dollar business, but has done little to improve our health-care outcomes Hidden to consumers, patient medical data has become a multibillion-dollar worldwide trade industry between our health-care providers, drug companies, and a complex web of middlemen. This great medical-data bazaar sells copies of the prescription you recently filled, your hospital records, insurance claims, blood-test results, and more, stripped of your name but possibly with identifiers such as year of birth, gender, and doctor. As computing grows ever more sophisticated, patient dossiers become increasingly vulnerable to reidentification and the possibility of being targeted by identity thieves or hackers. Paradoxically, comprehensive electronic files for patient treatment—the reason medical data exists in the first place—remain an elusive goal. Even today, patients or their doctors rarely have easy access to comprehensive records that could improve care. In the evolution of medical data, the instinct for profit has outstripped patient needs. This book tells the human, behind-the-scenes story of how such a system evolved internationally. It begins with New York advertising man Ludwig Wolfgang Frohlich, who founded IMS Health, the world’s dominant health-data miner, in the 1950s. IMS Health now gathers patient medical data from more than 45 billion transactions annually from 780,000 data feeds in more than 100 countries. Our Bodies, Our Data uncovers some of Frohlich’s hidden past and follows the story of what happened in the following decades. This is both a story about medicine and medical practice, and about big business and maximizing profits, and the places these meet, places most patients would like to believe are off-limits. Our Bodies, Our Data seeks to spark debate on how we can best balance the promise big data offers to advance medicine and improve lives while preserving the rights and interests of every patient. We, the public, deserve a say in this discussion. After all, it’s our data.

Download or read book Integrated Electronic Health Records written by M. Beth Shanholtzer and published by McGraw-Hill Education. This book was released on 2020-06-11 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: Developed as a comprehensive learning resource, this hands-on course for Integrated Electronic Health Records is offered through McGraw Hill's Connect. Connect uses the latest technology and learning techniques to better connect professors to their students, and students to the information and customized resources they need to master a subject. Both the worktext and the online course include coverage of EHRclinic, an education-based EHR solution for online electronic health records, practice management applications, and interoperable physician-based functionality. EHRclinic will be used to demonstrate the key applications of electronic health records. Attention is paid to providing the "why"behind each task, so that the reader can accumulate transferable skills. The coverage is focused on using an EHR program in a doctor's office, while providing additional information on how tasks might also be completed in a hospital setting.

Download or read book Charting Spiritual Care written by Simon Peng-Keller and published by Springer Nature. This book was released on 2020-08-10 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: This open access volume is the first academic book on the controversial issue of including spiritual care in integrated electronic medical records (EMR). Based on an international study group comprising researchers from Europe (The Netherlands, Belgium and Switzerland), the United States, Canada, and Australia, this edited collection provides an overview of different charting practices and experiences in various countries and healthcare contexts. Encompassing case studies and analyses of theological, ethical, legal, healthcare policy, and practical issues, the volume is a groundbreaking reference for future discussion, research, and strategic planning for inter- or multi-faith healthcare chaplains and other spiritual care providers involved in the new field of documenting spiritual care in EMR. Topics explored among the chapters include: Spiritual Care Charting/Documenting/Recording/Assessment Charting Spiritual Care: Psychiatric and Psychotherapeutic Aspects Palliative Chaplain Spiritual Assessment Progress Notes Charting Spiritual Care: Ethical Perspectives Charting Spiritual Care in Digital Health: Analyses and Perspectives Charting Spiritual Care: The Emerging Role of Chaplaincy Records in Global Health Care is an essential resource for researchers in interprofessional spiritual care and healthcare chaplaincy, healthcare chaplains and other spiritual caregivers (nurses, physicians, psychologists, etc.), practical theologians and health ethicists, and church and denominational representatives.

Download or read book The Computer Based Patient Record written by Committee on Improving the Patient Record and published by National Academies Press. This book was released on 1997-10-28 with total page 257 pages. Available in PDF, EPUB and Kindle. Book excerpt: Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Download or read book The Health Care Handbook written by Elisabeth T. Askin and published by Lippincott Williams & Wilkins. This book was released on 2022-11-21 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: Described in the New York Times as “an astonishingly clear ‘user’s manual’ that explains our health care system and the policies that will change it,” The Health Care Handbook, by Drs. Elisabeth Askin and Nathan Moore, offers a practical, neutral, and readable overview of the U.S. health care system in a compact, convenient format. The fully revised third edition provides concise coverage on health care delivery, insurance and economics, policy, and reform—all critical components of the system in which health care professionals work. Written in a conversational and accessible tone, this popular, highly regarded handbook serves as a “one stop shop” for essential facts, systems, concepts, and analysis of the U.S. health care system, providing the tools you need to confidently evaluate current health care policy and controversies.

Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 385 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Download or read book Medical Records written by GD Mogli and published by Jaypee Brothers Medical Publishers. This book was released on 2017-02-27 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Part 1: Traditional Medical Records Organization and Management Procedures Chapter 1: History of Medical Records Administration Chapter 2: Role of Medical Records in Health Care Delivery Chapter 3: General Medical Records Standards and Policies Chapter 4: Legal Aspects of Medical Records and Electronic Health Records (EHRs) Chapter 5: Medical Audit Chapter 6: ICD-10 Revision, ICD-10CM and ICD-10 PCS Revision Chapter 7: Hospital Information System Chapter 8: How to Economize Health Service Expenditure Chapter 9: Organization and Management of the Medical Record Department Chapter 10: Medical Record Procedures Part 2: Design and Development of Hospital Information System (HIS) for Software Production Chapter 11: Computerization of the Medical Records Chapter 12: Challenges of the Health Care Delivery in 21st Century Chapter 13: Domain for Designing the Hospital Information System (HIS) Software Chapter 14: Designing the Hospital Ward Nursing Administrative Activities Chapter 15: Blood Transfusion Service Chapter 16: Pediatric Center Chapter 17: Diabetic Center Chapter 18: Dialysis Center Chapter 19: Dental Clinic Chapter 20: IVF (In Vitro Fertilization) Clinic Chapter 21: Occupational Health and Safety Chapter 22: Biomedical Equipment Maintenance Part 3: Development and Implementation of Electronic Health Records (EHR) Chapter 23: Perspective of Information Technology (IT) in Hospital Information System Chapter 24: Challenges in Hospital IT and Networking Design Chapter 25: Tips for Evaluation of Electronic Health Record Software Chapter 26: Roadmap for Successful Implementaion of EHR Chapter 27: Amalgamation of Manual Record (MR) with Electronic Health Records (EHRs) Chapter 28: Health Record Manager (HRM) Revolves around Patient as a Good Leader Chapter 29: Modern Trends and Issues of Developing Countries in Maintaining Medical Records Chapter 30: Health Information Management (HIM) Professionals Endurance in 21st Century Chapter 31: Implementation of Personal Health Record (PHR) Bibliography Appendix

Download or read book The Clinical Documentation Sourcebook written by Donald E. Wiger and published by John Wiley & Sons. This book was released on 2010-02-02 with total page 338 pages. Available in PDF, EPUB and Kindle. Book excerpt: All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Download or read book Handbook of EHealth Evaluation written by Francis Yin Yee Lau and published by . This book was released on 2016-11 with total page 487 pages. Available in PDF, EPUB and Kindle. Book excerpt: To order please visit https://onlineacademiccommunity.uvic.ca/press/books/ordering/

Download or read book A Handbook of Medical Astrology written by Jane Ridder-Patrick and published by Crabapple Press. This book was released on 2006-12 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ridder-Patrick's classic and comprehensive work on both traditional and modern psychosomatic medical astrology describes the meanings of the planets, aspects, signs houses, and degree areas. It includes a step-by-step guide to decumbiture charts and astro-medical consultations, complete with possible remedies.

Download or read book Key Capabilities of an Electronic Health Record System written by Institute of Medicine and published by National Academies Press. This book was released on 2003-07-31 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt: Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.

Download or read book Big Brother in the Exam Room written by Twila Brase and published by Beaver's Pond Press. This book was released on 2018 with total page 464 pages. Available in PDF, EPUB and Kindle. Book excerpt: There are serious dangers lurking behind the government's $30 billion electronic health record (EHR) experiment. This omnipresent technology turns doctors into data clerks and shifts attention from patients to paperwork-while health plans, government agencies, and the health data industry profit. Patients who think the HIPAA ''privacy'' rule protects the confidentiality of their medical information will be shocked to discover it makes their medical records an open book. Inside this book, discover: - how Congress forced doctors to install surveillance in the exam room - hard facts from over 125 studies and reports about the impact of EHRs on medical care, costs, patient safety, and more - how patient treatment decisions are controlled (and tracked) by the EHR - what specific steps back to freedom, privacy, and patient safety are available, and why we must act now.