Your documentation is no longer a side project, instead, here's 7 reasons why documentation is foundational for your success:
- 1) Reduced Time Waste. Consistency equals efficiency.
- 2) Fewer Errors.
- 3) Superior Customer Service.
- 4) Lower Training Costs.
- 5) Competitive Advantage.
- 6) Greater Accessibility.
- 7) Trusted Security.
The importance of documentation (i.e. why should you care about this?)
- A single source of truth saves time and energy.
- Documentation is essential to quality and process control.
- Documentation cuts down duplicative work.
- It makes hiring and onboarding so much easier.
- A single source of truth makes everyone smarter.
Failure of the provider/licensee to meet the requirements of the regulations constitutes evidence of noncompliance regardless of the presence of outcomes. The purpose of these Principles of Documentation is to provide structure and consistency to the documentation of a citation.
Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. Documentation can be provided on paper, online, or on digital or analog media, such as audio tape or CDs.
It tells the patient's "story": the presenting problem and the treatment received; Helps to plan and evaluate a patient's treatment; Creates a permanent record for the patient's future care; Builds a database to evaluate the effectiveness of treatment that may be useful for research and education.
There are two types of documentation that should be produced when creating a new system:
- User documentation.
- Technical documentation.
The primary purpose of a medical record is to provide a complete and accurate description of the patient's medical history. This includes medical conditions, diagnoses, the care and treatment you provide, and results of such treatments.
A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care.
The goal of the forensic document examiner is to systematically evaluate the attributes and characteristics of a document in order to reveal how it was prepared or how it may have been modified.
The purpose of healthcare policy and procedures is to communicate to employees the desired outcomes of the organization. They help employees understand their roles and responsibilities within the organization.
What does ISO stand for? International Organization for Standardization. What is Health Level Seven International (HL7)? Develops messaging, data content and document standards for the exchange of clinical information.
What types of care plans are used in implementation? Standing orders that describe specific actions to be taken by a nurse., General protocols that apply to patients with similar clinical needs., Care pathways that combine several areas of health care expertise.
What are the advantages and disadvantages of SOR? PROS: Each discipline can easily find and chart pertinent data. CONS: Data are fragmented, making difficult to track problems chronologically with input from different groups of professionals. -Organized around a patient's problem.
A medical chart is a complete record of a patient's key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
In addition to providing records that manage and document the patient's care, medical records are used in reimbursement, research, and legal issues. Because the medical record is a legal document, many rules and regulations apply, including regulations on documentation, record retention, privacy acts, and disclosure.
What is the defining characteristic of an integrated health record format? Integrated health record components are arranged in strict chronological order. Critique this statement: Electronic health record systems have the same access control requirements as paper based record systems. This is a true statement.
Charting provides a record for communication, continuity of care, quality improvement, planning and evaluation of client outcomes, and legal protection, among other things.
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
RATIONALE: Effective documentation saves time in finding the patient's details, change in status, treatment plans, and the treatments administered. It minimizes errors in treatment because all the details are mentioned in the document.
Terms in this set (28)
- reduced medical error by keeping prescription, allergies and information organized.
- reduced costs by preventing duplicate text.
- more legible than handwritten document.
- more secure requires password.
- less storage space.
- information can be accessed from multiple locations.
Terms in this set (28)
- Fact sheet.
- Physician's orders.
- Graphic sheet.
- Nursing care plan.
- Nurse's notes.
- Care flow sheet.
- Medication administration record (MAR)
- History and physical examination forms.
Types of oral communication include formal communication, such as classroom lectures, speeches and meeting presentations; and informal communication, such as casual phone or dinner table conversations.
Terms in this set (8)
- Oral communication. Oral communication means communicating.
- Face to face.
- Meetings.
- Presentations.
- Performance Review.
- Apprisals.
- Telephone calls.
- Annual General Meetings (AGMs)
This includes the traditional: right patient, right medication, right dose, right route and right time. However, the additional five are stressed as equally important: right assessment, right to refuse, right teaching, right evaluation and right documentation.
Do's
- Before entering anything, ensure the correct chart is being used.
- Ensure all documentation reflects the nursing process and the full extent of a nurse's professional capabilities.
- Always use complete descriptions.
- Chart the time medication was administered, the administration route, and the patient response.
Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations. In this same manor, it is important to record information that can help support the proper treatment plan and the reasoning for such services.
Document is described as any written or electronically generated information about a patient status or the care or the service provided to that patient. Nursing documentation is the record of nursing care that is planned and delivered to individual client.
Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time.
Some of the most common deficiencies found in documentation are:
- Lack of patient signature, such as:
- Physician orders/scripts missing, incomplete, or not current, and/or illegible.
- Missing pages within the documentation.
- Missing or wrong date of service.
- Missing and/or improperly reporting CPT®/HCPCS Level II modifiers.
