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Point of Care Documentation

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Unit Assignments

Unit I Essay

Point of Care Documentation

After reading the required chapter on Electronic Health Records–An Overview, complete and submit the following in an APA formatted scholarly essay:

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  • Begin your essay with an introduction explaining the purpose of the essay.
  • In no more than three paragraphs, describe three electronic health record devices used to document point of care.
  • Describe the advantages and disadvantages of electronic health records being used at the point of care.
  • In no more than two paragraphs provide a summary of a recent doctor’s visit where an electronic health record device was used at point of care for you or a family member. 
  • Important reminder, do not forget to include a reference page, including all sources cited in your essay. The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism. 

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit II Essay

EHR Code Sets 

After reading the required chapters on Functional EHR systems and Learning Medical Record Software, complete and submit the following in an APA formatted scholarly essay:

  • Begin your essay with an introduction explaining the purpose of the essay.
  • In no more than four paragraphs, describe four EHR code sets.
  • Describe the similarities and differences of the EHR code sets.
  • In no more than one paragraph discuss why an EHR code set has to provide equilibrium between granularity and point of care requirements. 
  • Important reminder, do not forget to include a reference page, including all sources cited in your essay.
  • The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism. 

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit III Essay

Data Entry at the Point of Care

After reading the required chapters on Increased Familiarity with the Software and Data Entry at the Point of Care, complete and submit the following in an APA formatted scholarly essay:

  • Begin your essay with an introduction explaining the purpose of the essay.
  • Discuss the components of SOAP charting for the following scenario (include the list and forms that may be used): 

A 21-year-old female has come to the physician complaining of chest pain with shortness of breath. She says she has been wheezing and coughing for one week. Her vital signs are P-150, B/P – 150/100, R – 60, T-99.6. Following physical examination, the physician decides she has been experiencing tachycardia and has seasonal asthma. The physician gives the Medical Assistant an order to administer a breathing treatment using the nebulizer and 2.0 mg of albuterol sulfate. Then the Medical Assistant is to take the female’s vital signs again. 

  • Important reminder – do not forget to include a reference page, including all sources cited in your essay. The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit IV Essay

Understanding Electronic Orders

After reading the required chapters on Understanding Electronic Orders and Problem Lists, Results Management, and Trending, complete and submit the following in an APA formatted scholarly essay:

  • Begin your essay with an introduction explaining the purpose of the essay.
  • In no more than three paragraphs, describe the five basic rights of drug administration that must be followed to ensure that the physician administers the drug correctly.
  • In no more than two paragraphs, describe the legal and ethical issues surround handling medication errors.
  • In no more than one paragraph discuss the components of SOAP charting for the following scenario (include the list and forms that may be used): 

A 35 year old female in her second trimester of pregnancy calls the OBGYN office stating she has acid reflux. She states prior to pregnancy, she used to take Tagamet and wants to ensure that it is still ok to take being pregnant. How can you find this information and what should you do once you locate it?

  • Important reminder, do not forget to include a reference page, including all sources cited in your essay. The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit V Essay

Data Entry Using Flow Sheets

After reading the required chapters on Data Entry Using Flow Sheets and Anatomical Drawings and Using the EHR to Improve Patient Health, complete and submit the following in an APA formatted scholarly essay:

  • Begin your essay with an introduction explaining the purpose of the essay.
  • In no more than two paragraphs, describe the purpose of flow sheets in a medical environment. Explain how flow sheets are used in Obstetric offices and chronic disease management.
  • In no more than one paragraphs, describe the purpose of a problem-oriented flow sheet. Explain the difference between a Form-based flow sheet and a problem-oriented flow sheet.
  • Important reminder, do not forget to include a reference page, including all sources cited in your essay. The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit VI Essay

Privacy and Security of Health Records 

HIPAA demands that all patients are able to retrieve their medical records, amend inaccuracies or exclusions, and be informed on how their PHI is shared with third parties. HIPAA provisions that has led to a widespread overhauling in electronic medical records. HIPAA Laws and Regulations are divided into five Rules:

  1. Privacy Rule
  2. Security Rule
  3. Transactions Rule
  4. Identifiers Rule
  5. Enforcement Rule
  6. HITECH Act 

After reading the required chapter on Privacy and Security of Health Records, complete and submit the following in an APA formatted scholarly essay:

  • Begin your essay with an introduction explaining the purpose of the essay.
  • In no more than three paragraphs explain the five Rules of HIPAA Laws and Regulations.
  • In no more than one paragraph, describe the proper protocol for handling the following scenario under the HIPAA guidelines. Scenario: 

A clinician enters orders and requests labs in an electronic patient record, and then leaves the computer without logging off properly. You are working in the area and notice that the computer is on, but you assume someone is coming back in a minute. Meanwhile, a patient wandering the hallway notices that the computer is on and reviews her friend’s patient record. Who is responsible for the patient’s lost privacy? What corrective measures should be taken to ensure the breach of PHI does not happen again.

  • Important reminder, do not forget to include a reference page, including all sources cited in your essay. The essay requires a minimum 500 word response.
  • Submit before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Research Paper using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit VII Case Study

Using the Internet to Expedite Patient Care

Shon Brown, a 35-year-old male, arrives at his primary physician with complaints of a “cough and shortness of breath that will not go away.” He states that he has had a bark-like cough, pain in extremities, and fever for at least four days and feels like his symptoms are worsening rather than subsiding. When asked, he states that he did not take the flu shot this year. After a routine physical examination, Dr. Williams orders a CBC, chest X-ray, and CT of the chest, with and without contrast, and gives him a prescription for a cough suppressant and antibiotics. Dr. Williams will be in touch with him after the lab work and diagnostic procedure findings are in:

  1. Shon’s lab and diagnostic findings are indicating pneumonia. You are to create a letter to him, per Dr. Williams, stating his findings are positive for pneumonia (acute pathology) and he should contact the office for a flu shot when he feels better.
  2. You have a consent to use E-mail communication on file for Shon. Write an e-mail to him about his lab and diagnostic test results, requesting he contact the office by telephone or internet to arrange an appointment to receive a flu shot. 

After reading the required chapter on Using the Internet to Expedite Patient Care, complete and submit the following in an APA format:

  • Begin your case study with an introduction explaining the purpose of the case study.
  • In no more than two paragraphs explain what a Public Health Record is, what is comprised of, and who (patient, agency, committee, etc.) regulates entry to the PHR?
  • Write an e-mail to Shon about his lab and diagnostic test results, requesting he contact the office by telephone or internet to arrange an appointment to receive a flu shot. 
  • Important reminder – do not forget to include a reference page, including all sources cited in your essay. Upload before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Case Study using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.

Unit VIII Case Study

EHR Coding and Reimbursement

A 16-year-old female who has asthma has an Emergency Department visit for angina, shortness of breath, and wheezing. The doctor performs a chest x-ray, breathing treatments, and a Nuclear Medicine Stress Test utilizing a treadmill while monitoring the patient’s heart palpitations. While the patient is in the ED, the doctor evaluates her asthma and changes her prescription medication.

Review the chapter and consider the following questions:

  1. How would you select the ICD-9 and CPT codes for the procedural claim (encounter) for the ED visit?
  2. What diagnosis and procedure codes will result in full reimbursement for the procedures rendered?
  3. How will the claim demonstrate the medical necessity for the exams?

After reading the required chapter on EHR Coding and Reimbursement complete and submit the following in an APA format:

  • Begin your case study with an introduction explaining the purpose of the case study.
  • In no more than three paragraphs explain and answer the questions listed above. Be descriptive on the steps necessary to perform the above scenario. Defend your response and use terminology related to the scenario.
  • Describe billing upcoding and downcoding. Describe the penalties related to performing these tasks. Is there a chance for the scenario listed above to be upcoded or downcoded? Explain your response. 
  • Important reminder, do not forget to include a reference page, including all sources cited in your essay. Upload before the assignment deadline.

Be sure to support your work with specific citations from this week’s required reading and any additional resources.Format your Case Study using APA style. Use your own words, and include citations and references as needed to avoid plagiarism.

Information about accessing the Blackboard Grading Rubric for this assignment is provided below.