Evaluation Of The Medical Patient Records

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

2007, Pp.206-212). Working towards, and gaining knowledge of all skills, and the importance of communication has allowed me to strengthen my own understanding when communicating with others. As a student nurse, I need to understand the importance and reliance of my record keeping, to the continuity of care for patients. It is imperative that any nursing records I keep is complete, is accurate to prevent potential miscommunication and mistakes, and must be countersigned by a registered nurse. Notes should include the status of the patient and patient’s wishes, so that appropriate actions can be taken and in accordance with those wishes. Unless the patient lacks the mental capacity, then alternatively would act in the best interests of the patient according to: The Mental Capacity Act (2005). The patient’s notes should also emphasise the intervention outcome, I too need to be conscious of the language used within documents is clear, so others can understand it. Under the Data Protection Act (1998), I have a professional legal duty to keep all documents which I’m responsible for, confidential at all times. Documentation of clinical records, will help ensure that I am encouraging

Records are kept to promote, provide and improve the care provided for patients. They are also used for audits and quality assurance carried out by the Care Quality Commission (CQC).

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Include documentation in nursing flow sheet, nursing notes, or physician orders. Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes.

In health and social care recordings and use of measures are a vital signs for determine a patients state of health. This is so important which will decide the appropriate treatment a patient need and in which condition this patient health is at present. Nurses see the patient more than any other care provider. For that reason. Nurses are in the best position to observe the patient’s development, finding problems early and judge what care is needed to resolve the problem. The care provider always checks the charts and recordings before entering into the

Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness

Furthermore, during a medical emergency, physicians, or nurses who do not have time to access a computer for terminal cases can just simply grab patient’s chart (Tsai, Jack.2008). It’s like when a time is of the essence, paper records can make a difference. In addition, with paper health record it is stored in either a big warehouse or lock cabinet and only authorized personnel can obtain the medical records.

Medical documentation is important to know and complete properly to ensure that the office or practice you are employed with does not get flagged during an audit. Paying close attention to detail is key!

A lot of things have evolved when it comes to patient records in the medical field. In medical facilities the patient records use to be in paper form. There would be multiple pages of patient information, doctor

Documentation is one of the key criteria to be successful in the field of nursing. There is a saying in nursing. If it wasn't documented, then it wasn't done(TXBON). Producing a well-written document is very important because as a nurse, the ability to record correctly, with punctuation, choice of words

A medical record, whether in a physical record or an electronic form is a legal document that should “reflect an accurate chronology of events” (Brous, E., 01 Feb., 2009, para. 2). Without exception, every entry must be dated with a year, time recorded with either am, pm, or in military time, and the medical record should be signed with a last name and the doctor’s status. Furthermore, the medical record should read like a book; as well as paint a picture of the patient so that others who reach the chart will know what the doctor saw and did to the patient. Doctors that document about the patient and what the

Electronic Nursing documentation increased health care quality for the patient. This can be seen because electronic documentation is done at each interaction that takes place within the patient’s room. This is known as point of care documentation (Duffy,Kharasch, Hongyan, 2010). Another benefit to documenting at the bedside is nurses have to physical see the patient in order to complete documentation, therefore increase

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.