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Aug 6th, 2022
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How to Correct text in the Professional Medical History

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Dr. Rishi Desai here from Osmosis. and Im going to talk to you today about three tips to taking a really good patient history really important stuff. My advice to you again is, of course, you know how to get a patient history. the mechanics of it are pretty straightforward in the sense of you have a chief complaint, a main issue that they are therefore sometimes called presenting complaint. And then you have that HPI, the History of Present Illness. You have the past medical history, the medications and allergies, family history, social history, all that kind of stuff, review of systems thats the mechanics of it. But my tips on how to do a good job getting it. Thats what were here for. So lets start with my first tip, which is listen well and empathize. So keep in mind. The person is coming to you, They could go to a robot and then they can get all these questions answered. like, how long has the pain been there? where does it radiate to? All that stuff a robot can tell them or

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In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
Documentation is utilized to determine the severity of illness, the intensity of services, and the quality of care provided upon which payment or reimbursement of health care services is based. Data from documentation provides information about patient characteristics and care outcomes.
When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). Initial and date the entry. State the reason for the error (i.e. in the margin or above the note if room). Document the correct information.
Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse.
Modifications of the medical record by patients Generally speaking, patients should not be permitted to unilaterally modify a physicians entry. While a patient can request that the record be changed, the physician ultimately must agree that the request is necessary to correct an incomplete or inaccurate record.
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.
Good documentation is important to protect you the provider. Good documentation can help you avoid liability and keep out of fraud and abuse trouble. If your records do not justify the items or services for which you billed, you may have to pay that money back.
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.
7 Reasons Documentation is Critical to Your Medical Practice Reason #1: Documentation Meets Reimbursement Requirements. Reason #2: Documentation Improves Patient Care Across Multiple Facilities. Reason #3: Enhance Patient Communication. Reason #4: Improve Patient Recall. Reason #5: Help Evaluate Effectiveness.
Leave the entry as is and tell the charge nurse. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurses initials and followed by the correct entry.

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