Easily Remove Calculations in the Medical History

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How to Remove Calculations in the Medical History

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in this video were going to document the process for a specialist or any medical provider for that matter to document a medical problem and add it to the patients problem list we will also then go over the method for them removing it from the problem list but adding it to the patients past medical history for historical purposes as well as documenting any surgical or procedural intervention which may have been performed in this example Im going to give this patient and diagnosis of gall stones I searched for it Im going to choose this one notice that once Ive added it theres this box that says PL PL means problem list so if I check this then it will remain on the problem list forever or until another provider goes ahead and removes it in this case Im assuming the role of a general surgeon whos seeing a patient in consultation for gall stones Ive seen them at the visit Ive documented that they have gall stones I can also this moment make some diagnostic specific notes if I cl

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What are the consequences of incorrect medical records?

These types of errors in medical records can result in complications, adverse drug interactions, serious allergic reactions, or the provision of the wrong types of treatment. Any of these types of problems can cause the patient to suffer serious injuries or to potentially die.

Why is history taking critical for a medical record?

The details of their family and social history provide context for their medical care. All serious illnesses including surgeries, injuries, and hospitalizations are recorded. The status of preventative care is also established. Verification of these events by review of the previous medical records is advised.

What is the proper action if you make a mistake while charting written patient documentation?

Make the correction in a way that preserves the original entry. Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, mistaken entry, wrong medication name written.

What should a patient do if they discover incorrect information in their medical record?

Corrections. If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

What are the steps that should be followed when correcting an error in a medical record?

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.

What is a problem list example?

Examples of problems include health, psychiatric, nursing, dental, social, and preventive care. In addition, important events are often listed in the problem list, such as procedures, allergic reaction, complications from treatment and so on.

What should you do if you are cheating in the medical record and make a mistake?

Contact the hospital or your payer to ask if they have a form they require for making amendments to your medical records. If so, ask them to email, fax, or mail a copy to you.

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Remove Calculations in the Medical History