20. Data Entry in hospital .pptx

data entry in hospital

1. Data Entry in Hospital

2. Data Entry in Hospital D ata entry is the process of electronically capturing and recording various types of information crucial for patient care, administrative purposes, and billing

3. Importance of Data Entry Reduce Errors Enhanced Communication Reduced Administrative Burden Improved Scheduling Faster Billing and Reimbursement Easy storing and managing patient information

4. Types of Data Entry in Hospital Hospital Records Data Entry Surgical Records Data Entry Tests or Lab Records Data Entry Clinical and Healthcare Records Patient Information Patient Appointments Data Entry Medical Insurance Claim Forms Image Record Data Entry Patient Account Details Entry

5. Hospital Medical Data Entry Vital Signs:  Recording patient vitals like temperature, blood pressure, heart rate, and respiration rate into electronic health records (EHR) or charts. Intake and Output:  Documenting fluid intake and output to monitor patient hydration status. Pain Assessments:  Entering pain scores using standardized scales. Medication Administration:  Recording medications administered to patients, including dosage, route, and time. Nurses Notes: Documenting observations, assessments, interventions, and patient responses throughout the shift.

6. Hospital Medical Data Entry Indirect Data Entry: Verifying Information:  Nurses review pre-populated patient information for accuracy and update as needed. Providing Additional Details:  Nurses may clarify or add details to physician orders or progress notes. Flagging Inconsistencies:  Identifying discrepancies in the patient record and notifying the appropriate personnel.

7. Surgical Data Entry Pre-operative Data Pre-surgical assessment findings Allergies and medications Informed consent documentation Intra-operative Data Time of incision and closure Blood loss Type of anesthesia used Instruments and supplies used Details of the surgical procedure Post-operative Data Vital signs Pain assessments Fluid intake and output Medications administered

8. Types of Data Entered in Laboratory Patient demographics (name, ID, date of birth) Test ordered (complete name, test code) Specimen information (type of sample, collection time) Test results (numerical values, positive/negative indicators) Reference ranges (normal values for the specific test)

9. Clinical and Health Care Records Electronic Medical Records (EMR):  Digital records containing patient demographics, medical history, diagnoses, medications, allergies, immunizations, procedures, and laboratory results. Patient Demographics:  Basic patient information like name, address, date of birth, insurance details. Clinical Notes:  Physician notes, nursing assessments, progress notes, discharge summaries. Imaging Results:  X-rays, MRIs, CT scans, and other diagnostic images. Laboratory Results:  Blood tests, urine tests, pathology reports.

10. Patient Information Demographic Information: This includes basic details about the patient that are essential for identification and administrative purposes. Here are some common examples: Full Name Date of Birth Address Phone Number Email Address (optional) Emergency Contact Information Gender Insurance Details

11. Medical Information This encompasses a more comprehensive set of data related to the patient's health history and current medical condition. Here are some key elements of medical information: Medical History: Past surgeries and procedures Past illnesses and chronic conditions Allergies to medications or substances Immunization records Family medical history (when relevant)

12. Medical Information Current Medical Condition: Presenting symptoms and complaints Vital signs (temperature, blood pressure, heart rate, respiration rate) Medications currently taken (prescription and over-the-counter) Social history (smoking habits, alcohol consumption, etc.) Lab test results Imaging results (X-rays, MRIs, etc.) Nursing assessments and progress notes Physician diagnoses and treatment plans

13. Information Collected During Appointment Scheduling Patient Demographics:  Name, date of birth, contact information (phone number, email). Reason for Visit:  Brief description of the patient's concern or the type of appointment needed. Insurance Information:  Insurance provider and policy details for billing purposes. Referral Information:  Referral details if the patient is referred by another healthcare provider. Appointment Availability:  Discussing available appointment slots with the patient and their preferences Online Appointment Scheduling:  Some facilities allow patients to schedule appointments online through a patient portal.

14. Data Entry in Medical Insurance Claim Form Patient Information:  Insured's name, address, date of birth, policy information. Insurance Information:  Insurance company details, policy number, group number (if applicable). Provider Information:  Physician or facility name, address, tax ID number. Patient Encounter Information:  Date of service, place of service (office, hospital), diagnosis codes, procedure codes, charges for services rendered. Certification:  Physician or authorized provider's signature and attesting statement.

15. Image record data entry Patient demographics Date of imaging study Type of imaging modality (X-ray, CT scan, etc.) Body part or area imaged Referring physician or ordering provider Findings or preliminary interpretations (based on physician notes)

16. Patient Billing Data Entry Patient Demographic Information: Full Name Date of Birth Address Phone Number (optional) Email Address (optional) Emergency Contact Information Gender Insurance Details (Insurance provider name, policy number, subscriber information)

17. Patient Billing Data Entry Encounter Information: Date of Service Place of Service (e.g., emergency room, outpatient clinic, inpatient room) Referring Physician (if applicable) Attending Physician

18. Patient Billing Data Entry Clinical Information: Diagnosis Codes (ICD-10): Standardized codes representing the patient's diagnoses based on the International Classification of Diseases. Procedure Codes (CPT): Standardized codes representing the procedures performed during the healthcare service based on the Current Procedural Terminology. Other Relevant Clinical Details: This may include information documented in the medical record that supports the codes used for billing, such as lab test results, imaging results, and physician notes (summaries or specific details depending on the situation).

19. Patient Billing Data Entry Charge Information: Healthcare providers or facility charges associated with each service rendered. This may include: Physician fees Facility fees for using hospital equipment or resources Medication charges Laboratory test charges Anesthesia charges