Describe the type of electronic medical record documentation platforms or documentation system you are utilizing in your practice setting (Drchronos). How is this system conducive to recording patient data needed to ensure comprehensive patient care and record selected data including ICD 9 and CPT codes? Describe how you applied the ICD and CPT Codes in your practicum to date.
include 3 references
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Introduction:
Electronic Medical Record (EMR) is a modern documentation system widely used in medical practices. It helps healthcare professionals to keep accurate patient records, make informed decisions, and provide comprehensive patient care. In this answer, we will discuss Drchrono, an EMR platform used in practice settings. We will describe how this system is conducive to recording patient data and how ICD and CPT codes are applied in practice.
Drchrono EMR Platform:
Drchrono is a web-based EMR platform that allows medical professionals to create and maintain patient records online. It is intuitive and user-friendly, allowing providers to record comprehensive patient data such as medical history, vital signs, laboratory results, radiology reports, and medications. It also facilitates documentation of patient encounters and enables providers to generate medical and billing reports seamlessly.
ICD and CPT Codes Application in Practice:
ICD and CPT codes are necessary for medical billing and reimbursement. ICD codes describe the patient’s diagnosis, while CPT codes document the medical services provided. In Drchrono, providers can easily apply these codes to patient records, ensuring that the documentation is accurate and complete.
In my practicum to date, I have applied ICD and CPT codes to patient records using Drchrono. I have learned how to select the appropriate ICD codes that best describe the patient’s diagnosis accurately. I have also documented the medical services provided using CPT codes. By doing so, I ensured that the billing process was accurate and that the patient received comprehensive care.
References:
1. Raghu TS, Vinayakumar AR. Electronic Medical Record: A Review on Current Applications and Implementation Challenges. J Healthc Commun. 2016;1(2):12.
2. Pahari DP, Mishra D, Jena SK. Electronic Medical Record: A Review on Current Scenario. Int J Comput Appl. 2017;169(9):16-19.
3. Watson DE, Tamblyn R. Electronic health records, clinical decision support, and the impact on medical education. Acad Med. 2010;85(11):1741-1748.
