Medical records inquiry into master patient index reflects patient demographic and medical information. The listing of patients can be selective, displayed by patient name, medical record number, guarantor name, patient social security number, guarantor social security number, phonetic, or date of birth. The first detail screen displays all patient demographic information, guarantor demographic information, who to notify in case of emergency, and other addition detailed information. There is access to all detailed visits, all diagnosis and operative coding, all orders with results, and vaccinations. When accessing visit information you can also update and review the chart status.
The diagnosis pending work sheet is printed daily by doctor and the work sheet is be displayed for medical records personnel to select patients to be coded. The user can also bypass the work sheet and select patients by account number. There is abstracting code screens to be completed for the medical records information. The coding abstract screen will allow the user to either use a third party diagnosis coding product or use the WinMed coding screens. Once the diagnosis/operative information has been input, the drg code will be updated and the coding and grouping will be completed.
The Medical Records reporting functions have detailed Statistical reporting which include statistical reporting by categories by service classifications. The categories include admissions, discharges, census days, deaths, autopsies, consultations, and discharge days. These categories will be summarized by service classifications. The chart status report shows each patient who has outstanding issues that need to be completed. The report functions also include all index reporting. The monthly reporting contains statistical data, death and infection reports, and diagnosis/operative indices.