Clean mark in the Professional Medical History

Aug 6th, 2022
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How to clean mark in the Professional Medical History

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to the modern mind many of the medical treatments of the past may seem barbaric cruel and primitive in a time when very little was understood about how the human body worked diseases were often believed to be caused by evil spirits or bad luck and treatments would often do more harm than good here are my choices for five of the most barbaric and dangerous medical practices from history number five treponation treponation is a surgical procedure in which a hole is drilled or scraped into a human skull thus exposing the brain to air in the belief that this will treat a wide variety of ailments there is evidence that treponation has been carried out since neolithic times and evidence of the practice has been found in cave paintings and at ancient burial sites those behaving abnormally might find themselves forced to have holes drilled in their heads in the belief that this will release the evil spirits causing their problems it was also used as a catch-all treatment for seizures epilepsy

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Documentation is essential to quality and process control There needs to be some level of cohesion so that you dont look sloppy or uninformed. Documentation encourages knowledge sharing, which empowers your team to understand how processes work and what finished projects typically look like.
Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patients history so they can continue to provide the best possible treatment for each individual.
HIPAA doesnt actually allow people to correct their medical records instead, it provides people with a right to amend the record by adding in additional information. But if a person wants to remove erroneous information, that person is generally out of luck.
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
Healthcare organizations maintain medical records for several key purposes: Patient Care. Patient records provide the documented basis for planning patient care and treatment. Communication. Legal documentation. Billing and reimbursement. Research and quality management.
If you want to have a mistake fixed, follow these steps: Step 1: Contact your provider. Contact your providers office and find out what their process is for updating or correcting your health record. Step 2: Write down what you want fixed. Step 3: Make a copy of your request. Step 4: Send your request. Troubleshooting Tip.
Medical records should be complete and legible. Documentation of each patient encounter should include: Reason for encounter and relevant history. Appropriate history and physical exam in relationship to the patients chief complaint.
Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, thats what really matters. Good documentation is important to protect you the provider.

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