Case Study Assigned: 38-year-old Native American pregnant female living on a reservation

How would your communication and interview techniques for building a health history differ with each patient?
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient. Keep in mind cultural differences that may apply.

**Include 3 sources

Question 1

Chapter Thirteen discusses the major elements of drama and distinguishes the form from other genres like the short story and poetry. Using the play Riders to the Sea (Synge) as an example, discuss what elements and qualities make drama unique as a literary form. Support your ideas with textual evidence from Synge’s play. In your post, take into consideration how the literary themes of Riders to the Sea relate to the dramatic form. 
 
Initial posts must be 200 to 300 words in length and posted by Day 3. Respond to at least two of your classmates’ posts.

Question 2

Medicare Reimbursement

This assignment will test your knowledge of reimbursement methods of the Medicare program. Below, there are five scenarios that deal with the reimbursement of services provided to a patient enrolled in the Medicare program. Pay close attention to the details in each scenario such as whether the provider accepts Medicare or not. Use Chapter 9 (starting on page 308 of the textbook) to help you with calculating reimbursement. Show your work.

Mr. Allgood was just discharged from Meadowview Medical Center after receiving a procedure on his left leg. Mr. Allgood has Medicare coverage, which Meadowview accepts as a participating provider. Meadowview charges $215 for the procedure and the Medicare Physician Fee Schedule (MPFS) for the procedure is $150. What amount would Medicare be responsible for paying?
Mrs. Holloway has just received a bill from Oceanside Surgery Center regarding her recent outpatient surgery. Oceanside accepts Medicare assignment and charges $1,000 for her surgery. The MPFS for this surgery is $917. Mrs. Holloway was billed $200 from Oceanside Surgery Center. Considering that Mrs. Holloway is enrolled in the Medicare program, was she billed the correct amount? Explain why or why not.
Mr. Tee underwent a medical procedure on his lower back and is a Medicare patient. Mr. Tee has a good rapport with a local medical provider and wants them to do the procedure on him. This local provider is a non-participating provider and does not accept assignment from Medicare. The MPFS for the lower back procedure was $849. What amount is Medicare responsible for paying? How much is the patient responsible for paying?
Ms. Poppins has just received treatment for an ailing hip from New Scenery Medical Group which accepts Medicare. New Scenery Medical Group charges $73 for the treatment provided to Ms. Poppins, and the MPFS for the treatment is $70. If Ms. Poppins is responsible for $14, how much can New Scenery Medical Group write-off as uncollectible?
Mr. Rogers was seen by Uptownship Health Care where he was provided medical services to address pain in his abdomen. This provider does not accept Medicare assignment and charges $750 for this type of service. The MPFS for the service is $615. Provide the amounts for the items listed below:
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Fundamentals of the Legal Health Record and Designated

Once again, AHIMA steps up and provides a thorough source to guide the HIM professional on a host of documentation issues. Some of this information leads into next week’s content regarding storage of sensitive PHI.

The guidance for designated records is particularly timely as health technology expands the types of records flowing into the PHI data set. Digital x-rays, scans, and other diagnostics, interoperability that provides for a host of consult dictation becoming part of the record, home monitoring, telemetry monitoring, and a myriad of other documents must be addressed. Should they be included or is a narrative sufficient? If included where are they stored? How long are they stored? What exactly does the EHR include?

Photo Credit: https://www.smartsheet.com/medical-records-management

For years healthcare organizations have struggled to define their legal health records and align them with the designated record set required by the HIPAA privacy rule. Questions often arise about the differences between the two sets because both identify information that must be disclosed upon request.

The expanding scope of health records adds to the challenge of defining and compiling these record sets. An individual’s record can consist of a facility’s record, outpatient diagnostic test results or therapies, pharmacy records, physician records, other care providers’ records, and the patient’s own personal health record. Administrative and financial documents and data may be intermingled with clinical data.

In addition, the type of media on which information is recorded is also expanding. Source records may include diagnostic images, video, voice files, and e-mail. The organization must determine which of these data elements, electronic-structured documents, images, audio files, and video files to include.

The emergence of electronic health records (EHRs) also is complicating organizational efforts to define and disclose information. Information in EHRs is often stored in multiple systems, inhibiting the ability to succinctly pull together the record for either the legal health record or the designated record set.

These input systems may include laboratory information, pharmacy information, picture archiving and communications, cardiology information, results reporting, computerized provider order entry, nurse care planning, transcription, document imaging, and fetal trace monitoring systems, as well as a myriad of home-grown or individual clinical department systems.

However, the same criteria that organizations used to determine what paper records to retain and include in their legal health records and designated record sets can be applied to electronic records. Questions organizations must ask include:

What information can be stored long term?

What is clinically useful long term?

What is the cost of storage?

How can the organization effectively and succinctly assemble the EHR for long-term use?

This practice brief compiles and updates guidance from four previously published practice briefs to provide an overview of the purposes of the designated record set and the legal health record and helps organizations identify what information to include in each. It also provides guidelines for disclosing health records from the sets. The four original practice briefs are listed in the “Sources” section at the end of this practice brief.

Fundamentals of the Legal Health Record and Designated Record Set

Provide a plan for guidance for defining of electronic record health sets based upon AHIMA standards.

Include each of the following aspects in the assignment:

Ø  Access the AHIMA document: Fundamentals of the Legal Health Record and Designated Record Set

Ø  Create a chart with columns to place each of the five criteria to evaluate when defining what is part of the HER

Ø  Locate the five criteria in the middle of the document

1.    Identify Relevant Regulations, Standards, and Laws

2.    Determine Records Created in the Course of Business

3.    Address Retention Requirements

4.    Consider How Data Would Be Produced

5.    Classify External Records

Ø  Place each criterion in a column and list how you will define each

Ø  Submit your Word document chart to the drop-box

Ø  Cite the AHIIMA reference. APA is not required but as always proper grammar, sentence structure and spelling is expected. There is NO copy/pasting. Everything must be in your own words.