Accurate Charting: A Case Study

For the verbal orders and read backs graph needs to be broken down into quarters. This would help address the problems sooner for the next fiscal year. During a department’s grand rounds, it needs to be reiterate the important of verbal orders and read backs are to patients’ safety. The smaller sample size may point to an individual doctor or nurse who needs retraining. This will help with orthopedics department improvement at fast rate and take other department to one hundred percent. The rush of the orders being given may lead to the using of impropriate use of abbreviations. The U abbreviation needs to be address in grand rounds of each department. The reporting of critical results need to address with laboratory staff and nurses, The doctors should be warned that when order something, “stat” to ask for the results within a reasonable amount of time. This will help in patient’s safety because it saves of life.

Although EMR’s may be taking over the medical world, paper medical charts remain the most well recognized form for keeping medical records. There are however some things within paper charts that some medical personnel might argue make it a primitive aspect of the medical field. One argument in itself is that the abundance of paper that is utilized in paper charting doesn’t stand up to the “green” society we aspire to live in today. “Paper charting used to take so long, the papers would always get unorganized, they took up so much room in the nurses’ station and the worst was waiting for a doctor to finish with a chart so I could chart what I needed to” (Brittney Guggino LPN, 2012). Another acknowledged concern with paper medical charts is the illegible handwriting of clinicians, which is a common, longstanding problem. Being unable to read orders clearly creates an added risk when dealing with patients treatments, medications etc. Paper charts may be familiar but they come with many downfalls and it’s these downfalls which may sway a person’s decision in the opposite direction in regards to the

Due to the recent economy situation and ever challenging business environment, for the whole of last year, the company recorded cost hike and sales decline. This has impacted the bottom line (profitability) of the company. The top management sees that urgent action plans need to be put in place for continuous survival of the company.

Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).

The  Medicine Administration Record (MAR) chart should record what is on the box of medication including full name, address and date of birth of the patient to ensure the prescription is correct for that person. It should also have the date to ensure the

The first edition helped reassure the use of customary terms and clarifications to record procedures in the medical documents; delivered the foundation for a computer based system to assess and evaluate operational procedures; facilitated effective communication as precisely as possible for the data related to procedures and services to organizations connected with insurance claims and conveyed uncomplicated data for analyzation and statistical commitments. This first edition focused on procedures for surgeries and touched on some degree of laboratory, radiology, and prescription techniques. These restrictions encouraged the delivery of the second edition of CPT just four years later in 1970. With this subsequent publication there was a heightened

All PT’s follow the SOAP note format to document patient visits. SOAP notes were created to help keep consistency through the field and to keep patient records organized and secure. SOAP notes are written to help the PT critically think about the next step in their client’s rehabilitation process. The format is used “to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process” (Lowe “SOAP Notes”). SOAP documentations aid in informing and proving PT’s work. The content is straight to the point and remains strictly factual which causes shorter sentences. SOAP stands for subjective, objective, assessment, and plan (Lowe “SOAP Notes”). Each section aides in formulating an evaluation of the client’s visit. A PT uses APA citation if they

The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result

The pt. must have physical complaints that have been going on for a few years.

Documentation records is related to the quality of patient care provided. It signifies the primary communication among multidisciplinary caregivers for efficient and effective intial treatment, for continuing care, and for the evidence that care and treatment occure. Regulatory agencies use the documentation as a means to measure the quality of services before granting accreditation or certification to healthcare organiztions. Some of those agencies include:

Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report.

This lack of point of care charting, creates issues with late charting or missing charting. The purpose of this paper is to determine solutions to the barriers of point of care charting. Summary of Area of Interest Point of care charting is important for keeping the medical record up to date. In Hospice, we have 24 hour on call nursing.

As technical writers, we will use evaluation reports, daily progress notes, summary reports and discharge plans. Accuracy and attention to detail in the content of these reports is essential in treating and determining the progress of our patients.

Progress. Over the last decade, the hospital has made a lot of progress regarding the use of HER’s. After the CPSI system was initiated, the transition from paper charts to computer charts began. Today, all charting is done electronically by all members of the healthcare team. From the dieticians to the physicians, everyone is trained and

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.