Aspects of Psychology - Disease Process, Classification, and Reimbursement Methods (U3IP&DB) - Essay Example

Aspects of Psychology - Disease Process, ification, and Reimbursement Methods (U3IP&DB) Part I According to the New Jersey Hospital Association(2008, pg. 1), “A medical record is defined as ‘A file kept for each patient, maintained by the hospital (physicians also maintain medical records in their own practices), which documents the patients problems, diagnostic procedures, treatment, and outcome. Related documents, such as written consent for surgery and other procedures, are also included in the record.

Occasionally a hospital keeps a separate medical record for each hospitalization (hospital admission); the better practice is to use the ‘unit record system,’ that is, keep a ‘unit record’ for each patient, with all records of the patients successive hospitalizations in the patients unit file. The record itself is usually organized in either the ‘traditional’ or the clinical record, the patients chart, or simply the chart.” This is one way to keep information that is necessary to treat a patient together and organized, and it is highly comprehensive.

The unit record systems keeps details in chronological order, saves times, ensures up-to-date information, avoids multiple entries, is economical, and saves space. One common way of recording data is to use the Bradma data writing system, and “The Bradma card made of plastic contains the patients name, record No., address, year of birth, telephone number etc.” (Ramanand, Chandran, and Badrinath, 1982, pg. 1). The records contain referral letters, ophthalmology records, the case sheets, special specific medical record forms, admission records, discharge summaries, progress notes, operative orders, anaesthesia records, retina drawings, and graphic sheets.

The records are filed according to a serial filing system. They are coded according to ICD-9CM and indexed according to the patients’ alpha index, patients’ number index, diagnostic index, and operation index (Ramanand, Chandran, and Badrinath, 1982).ReferencesHospital, patient and medical records: FAQs. (2008). New Jersey Hospital Association. Retrieved June 23, 2008, from http://209.85.215.104/search?q=cache:OobispXxTRkJ:www.njha.com/librarysection/faq.aspx+%22unit+record+system%22+medical&hl=en&ct=clnk&cd=4&gl=usRamanand, B.C.; A.

Chandran; and S.S. Badrinath. (1982). Medical records in specialty hospitals. Indian Journal of Ophthalmology. Retrieved June 23, 2008, from http://www.ijo.in/article.asp?issn=0301-4738;year=1982;volume=30;issue=4;spage=363;epage=365;aulast=BhatPart IISource-Oriented Records These types of records are organized according to information that has been documented, and are the traditional types of medical records. Written entries are made by a patient’s different caregivers into these types of records using specialized forms.

“One of the criticisms of source-oriented records is that it is difficult to demonstrate a unified, cooperative approach for resolving the client’s problems among caregivers. Frequently the fragmented documentation gives the impression that each professional is working independently of the others” (Timby, 2004, pg. 112).Integrated Progress Notes Records “Integrated progress notes include notes of physicians, nurses, and ancillary professionals, for example, physical, respiratory, and occupational therapists, social service, and nutrition.

These progress notes are usually integrated into a continuing chronological narrative” (Sharpe, 1999, pg. 97). While these are certainly comprehensive and helpful, this type of recordkeeping is not all-inclusive and is not as organized and comprehensive as the other methods studied.Problem-Oriented Records These types of records are organized according to a patient’s individual health problems. “In contrast to source-oriented records that contain numerous locations for information, problem-oriented records contain four major components: the data base, the problem list, the plan of care, and progress notes.

The information is compiled and arranged to emphasize goal-directed care, to promote recording of pertinent information, and to facilitate communication among healthcare professionals” (Timby, 2004, pg. 112). For this reason, I personally believe that problem-oriented records are the most effective and efficient.ReferencesSharpe, C.C. (1999). Medical records review and analysis. Greenwood Publishing Group. Retrieved June 23, 2008, from http://books.google.com/books?id=SkeBPgOJmr4C&pg=PA97&dq=integrated+progress+notes+records&sig=_ldzgbVjulOqIyY8s6iEVJeWMngTimby, B.K. (2004).

Fundamental nursing skills and concepts. Lippincott, Williams, and Wilkins. Retrieved June 23, 2008, from http://books.google.com/books?id=M4HwH5IxfToC&pg=PA112&dq=%22source+oriented+records%22&sig=CNbf59-icno-jwI1izUsrZ_rXu4