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oo STC 4G 8:37 PM e-12%D vle.au.edu.sa Health Information Management in Non Acut

ID: 125003 • Letter: O

Question

oo STC 4G 8:37 PM e-12%D vle.au.edu.sa Health Information Management in Non Acute Assignment 2 Due date (October 24, 2017 2 pm) Name: ID: Q1. List the major types of documentation that are basic to all ambulatory encounters and settings. 02. How is quality assessment in ambulatory care similar to and different from quality assessment in the acute inpatient setting? Q3. Describe the various appointment scheduling methods. Mention the advantages and the disadvantages of each. Q4. In dialysis facilities, why is documentation essential? And what are the two main forms in a dialysis patient record?

Explanation / Answer

Ambulatory health centers play a dramatic role in delivering health services within the reach of people and in simplest way at lower cost than reaching to hospitals.

1) The main documentation which are needed for ambulatory encounters or settings are as follows;

- History and physical examination formats for better assessment of patients and documentation can be used for future reference

- Progress notes to document the progression of the patient during care

- Facilities of Lab and X-Ray and related documents to conduct lab services. These are basic for easy analysis of disease process

- Encounter form with patient demographics and reason for referrals and reason for encounter with health care facility and health care workers

- Problem list which determines the complaints of patient

2) Ambulatory care settings provides services on outpatient basis. This includes observation, diagnosis, consultation with doctors, treatment with possible illnesses and rehabilitative services.

Onthe other hand, acute care settings where services are provided with immediate effect for serious illness or injuries.

The commonest thing in both the settings are the way an assessment is performed and the personnel's involved in the care. Training on patient assessment remains similar but there will be formats used for the assessment could change for both the settings.

The tools are different and availability of equipments vary because acute care settings have advanced technology like MRI and cathlab interventions whereas ambulatory settings may have limited services like X-Ray.

3) Types of scheduling methods-

- scheduling matrix which provides appointments to patients on the basis of working and non working hours of the service center.

It is very useful for patients who can pre plan the day and make their day freely available for receiving care

However, this might not be helpful for patients who need immediate care or medical assistance. And if the patient gets late to the center then may not receive the care after working hours.

- Stream scheduling is a type of appointment where the patient is given a pre determined date and time depending on the patients needs and health status.

It helps the client to come prepared on the day and easy queue management and need not wait for so long with waiting hours.

If becomes late for the appointment time then it get teachers at the last or on some other days.

- wave scheduling,where patient appointment is fixed in group on some time of the day, thinking that patient may not be available on time.

This helps in clearing large groups.

However, people need to wait for long hours

- modified wave scheduling

- double booking

- cluster booking

- Open office hours

4) Documentation is a crucial part of patient treatment as well as for organisation.

Documentation with completeness can speak better in legal implications.

Future references can be derived from older documents.

Dialysis patients comes a weekly basis and they are regular customers ,so maintaining documentation will give good retrospective information about the patient.

It can create safety of the patient and organisation

There are many documents followed in a dialysis unit but the below mentioned documents are very crucial;

1) Patient dialysis record which includes the events of dialysis on that specific date and one complete folder will comprise all the such records of the patient

2) Quality compliance record for water analysis, machine maintenance because these are very important to work efficiently