The Medical Records application area is used to manage a patient’s documentation and prepare visits for billing. Physicians, nurses, and staff are sometimes required to obtain specific information for a patient’s medical record for proper diagnosis and later reimbursement.
Medical Records helps manage that process, from maintaining and applying a variety of diagnosis, procedure, and payment codes to abstracting visits to prepare them for billing. Abstraction is the process of validating the complete and accurate medical record. Abstracting includes coding the account with illness classifications and treatment information (APC, HCPCS, DRG, etc.) that provides statistical analysis along with payment and reimbursement information. Once the account is abstracted, it is then ready for Billing.
Learn more about the Medical Records workspace, scorecards, and dashboards, by reading below.
The Medical Records workspace gives the user access to work queues, tabs, and Quick Actions related to coding. The data panel displays patient data (name, status, balance, etc.) and the User Productivity chart.
The Medical Records workspace is used to abstract visits and complete any required information for billing, including HCPCS coding, DRG code, diagnoses, physicians, etc. Patient information, including death information, can also be managed.
Quick Actions allow users to merge medical records and interact with external coders.
The Medical Records application area has multiple scorecards that measure productivity by work queue and by event.
The Registration scorecard displays the following information in the primary panel:
The other panels and charts allow the user to drill down to totals by work queue and user.
The Registration – Event scorecard displays the following information in the primary panel:
The other panels and charts allow the user to drill down to totals by event () and user.
The Medical Records application area includes dashboards that display a variety of financial, performance, and trending information. The following dashboards are available in Medical Records:
The Medical Records workspace includes a variety of standard work queues designed to complete tasks on visits related to admissions.
Medical Records’s base set of work queues includes: