DOCUMENTATION Documentation plays a very important part in the healthcare delivery system. It serves as a communication tool for all health care providers to ensure that there is continuous, safe, accurate, quality healthcare for each patient. Documentation also serves as protection for nurses, in case of any claim in regard to an alleged act of negligence or malpractice. When documenting nurses should always use factual, consistent, accurate, objective and subjective to ensure the patients progress and health care can be monitored. Nurses should always provide a rationale for any decision made. Jargons should be avoided when documenting to prevent any misunderstood communication. Can you imagine a paperless hospital? A hospital that doesn't …show more content…
The use of a nursing information system such as our Bar Code System, will document types of medications used in hospital settings catering to patient’s needs. It will also provide checks and double checks which is a valuable tool because it maintains the five rights of medication administration, notification are at the nurses finger tips, errors and warnings are readily available, allergy checking is automatically performed, dose checking and other relevant clinical data are …show more content…
Unfortunately proper assessment of a patient is not done due to the short staff of medical practitioners. What if I told you there is a way every patient can get a compassionate medical practitioner who would understand what is wrong with the patient and thoroughly explain what is happening, why it is happening and how to treat it all in the comfort of their home or somewhere convenient to them. This is very possible and it can be done by using Telehealth. Telehealth is using machine that can provide video conferencing with the doctor and patient. The machine is well designed and equip with high definition camera and audio that allows the medical practitioner to assess the patient. One might ask how a machine can allow an assessment via video conferencing. This is done because attached to the machine is an otoscope which is not like the traditional one, this otoscope has, installed in it high definition camera that can zoom in and other and capture clean digital pictures of the patient’s eyes or even the patient’s throat. Another equipment that is attached to the machine is a then stethoscope which provides the practitioner with audio of the lungs, heart, and
Procedural and Informational Documentation All information relating to the creation and
Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. It can have a negative impact on the hospital budgeting and financial planning process for the hospital. It is for this purpose that every healthcare institution should be purposeful on reviewing the accuracy and completeness in clinical documentation, no matter the cost. Even though, for most physicians, most of their time is focused on the actual care of the patient and there is little to no time to devote to extensive documentation, it is imperative to understand patient care includes both the one-to-one attention and the documentation of said treatment.
Use the hospital or facility policy if there is a correction that needs to be made in the document. Do not scratch out, use liquid paper, or conceal any documentation. This makes the nurse look like you are falsifying
Medical documents for example write policies and procedures based on evidence based practice leading to credibility of the
(Hogue & Prudhomme, 2012) Another point is documentation on a patient. There is a saying in the medical field if you didn’t document it didn’t happen, make sure as a case manager, everything you do is fully documented in the patient record. Develop habits that are good, you always want to document on a client when everything is fresh. It proves to the case manager’s credibility.
As a nursing student I am taught how to document using special medical terminology, and the importance of documenting, however the article “Stay Out of Court with Proper Documentation” by Sally Austin confirms just how critical it is to be accurate, timely, and unbiased with patient documentation. Proper documentation not only helps keep the patient safe, but just as importantly protects the nurse should a lawsuit occur. Austin’s article defines the legal terms used in the more common lawsuit, negligence, involving nurses and how to avoid them. First, the patient must prove four things in order for a lawsuit to be deemed in their favor: A duty to the patient existed, a breach of duty occurred, the patient was injured, and lastly the injury
Specificity of diagnosis, abnormal lab test and medication is often vital healthcare information in the medical record. Failure to document this information significantly slows hospitals from collecting the correct level of payment. Hospitals should not only target coders for performance improvement given that no level of accurate coding can overcome the lack of documentation. The Doctors that underdocument care and services provided represent the most significant opportunity to increase charge and reflect the severity level and provide adequate defense. When researched, Advisory Boards nationwide has uncovered multiple cases in which improved physician documentation has increased annual by 1.5 million.
The patients are on our hands and its important to treat them as we would like to be treated. They are counting on us.
When the Hospital Standardization Program established their initial set of minimum standards, one of the prescriptive measures required healthcare organizations to maintain medical records for patient treatment. The necessity of creating, and preserving a detailed account of a patient’s history, laboratory results, and treatment seems rudimentary today. The Hospital Standardization Program made significant advances in enforcing proper documentation. Building on that legacy, TJC strengthened standards involving appropriate medical documentation by including strict timelines for completion. For example, TJC mandates a patient’s History and Physical (H&P) report be completed within 24 hours of admission.
(2013), are implemented by hospitals to assure the health record accurately reflects the actual condition of the patient. AHIMA provides guidance for clinical improvement programs with goals which include identifying and clarifying missing, conflicting or nonspecific physician documentation related to diagnoses and procedures; supporting accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality which leads to appropriate reimbursement; promote health record completion during the patient’s course of care; improve communication between physicians and other members of the healthcare team; improve documentation to reflect quality and outcome scores and improve coders’ clinical knowledge. Developing a CDI program as a coding manager will include hiring credentialed and competent individuals with the right education and experience, providing training and in-services for staff and related departments that use clinical documentation on how specific and complete clinical documentation needs to be captured, making sure staff is knowledgeable in State and Federal laws and regulations that govern their positions, adheres to ethical standards set by credentialing and regulatory organizations and making sure staff is aware and exposed to changes and improvements in the industry through continued
Patients are our priority and when there is any complaint from their side, it should be handled and sorted
Alyssa Habner Assignment 3-1 Gary Mahon How does informatics improve patient safety? Three ways informatics increases patient safety: 1.) recognizing complications and offering evidence-based answers with their associated documents, 2.) By integrating precise evidence based and life-saving procedures, and 3.) the combination of new ethics and high levels of care.
The steps in the medical documentation process are: Register the patient. Use patient insurance information to verify eligibility. Establish patient financial responsibility post payment Code for services rendered submit claim check out patient continue to follow up with patient until patient is healthy The reason why medical documentation is required is because it is Important to keep track of the patient and their health status. Not to mention having medical documentation serves the purpose of billing insurance and medical liability.
Using data can better nursing practice, improve patient safety and quality of care. There are several interventions based on research evidence that can be applied. The goal is to reduce medication administration errors. A reduction in medication errors would not be 100%, however, a goal approach of 75%, and then 90% would be a significant improvement over time. The design of the automated dispensing system (BCMA), would have a great impact on how nurses deliver their medications (Franklin et al., 2007, p. 282).
o Food intake: Document the patient’s food and liquid intake. o Observation of the sick: Observe the patient, and document the observation. o Bed and bedding: Keep the bed comfortable, dry and wrinkle free.