MCKESSON LAB HI 160

Bailey Madelyn Wilson

ahima.demoservers.com/VTMS/

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There are 6 queues located in the Lab with 5 patients each. Pick 2 of the 6 queues to complete. (10 patients total)

Click on HPF Workstation

Students can log in using User Name “STUDENT01” through “STUDENT30” to search for available work queues. The password is “1234”.

Search Screen

To access the queues: Click on “To Do” and select “Queues” from the drop down box.

Queues are displayed with number of charts in each queue. Single click on an appropriate queue name (A - F) which contains five records.

Single click on a queue to open the list of the patient records in that queue Click on a name in the list. Click Process to process this record. Click the radio button for “Deficiencies”.

(The patient ‟ s name will appear at the far right side on the top green banner.) (The deficiency processing functions will open on the left side of the screen.) (An organizational tree with the pages of the medical record will open.) With the “CLINICAL” tab selected, open each form in the record by double clicking on the form in the organizational tree. Use the “Checklist for Quantitative Analysis” to search for deficiencies in the record.

Quantitative analysis

The Quadramed MPI simulations: How do these simulations, and the deficiencies they show relate to the concept of quantitative or analysis?

Quantitative analysis: The use of statistical techniques to understand quantitative data and to identify relationships between and among variables.

Checklist for Quantitative Analysis FACE SHEET  Patient name and MR number on all pages  Admitting diagnosis on face sheet  No abbreviations on face sheet  Discharge Instructions completed  Consent for Admission/Treatment  Admission Consent Signed ADVANCE DIRECTIVES  Advance Directives in each record or notation HISTORY AND PHYSICAL  History & physical within 24 hours of admission  Physical assessment  Psychological assessment  Social assessment  Nutrition and hydration status  Functional status  H&P signed

Checklist for Quantitative Analysis PROGRESS NOTES  Admitting Progress Note  Progress notes dated  Progress notes timed  Progress notes signed  Discharge progress note PHYSICIANS ORDERS  Physician orders dated  Physician orders timed  Physician orders signed  Results of diagnostic tests ordered  Consultation reports completed if ordered  Discharge order

Checklist for Quantitative Analysis SURGERY  Consent to surgery  Consent to surgery signed  Operative report completed  Operative report signed  Post-operative progress note immediately after surgery  Path report for specimen removed DISCHARGE DOCUMENTATION  Discharge order  Discharge summary complete  Discharge summary signed  Discharge status documented GENERAL DOCUMENTATION GUIDELINES  Check for missing text in narrative documents  Check for misfiles of reports in wrong patient records

Most common issues Missing signatures Missing Documents Illegible notes/signatures Incomplete notes