Lack Of Meticulous Documentation And Positive Patient Interactions Deter A Lawsuit Essay

purpose of this paper is to review the electronic medical record and analyze its impact on

Records contain very sensitive personal information; they are regarded as legal documents and are a legal requirement to be kept. All information written in files should always be clear, useful and relevant. Do not include anything irrelevant or opinions that are not backed up by facts. Only the patient whose notes you are writing in should be written about and all entries should be clear, factual and true.

Medical malpractice lawsuits are an extremely serious topic and have affected numerous patients, doctors, and hospitals across the country. Medical malpractice is defined as “improper, unskilled or negligent treatment of a patient by a physician, dentist, nurse, pharmacist, or other health care professional” (Medical malpractice, n.d.). If a doctor acts negligent and causes harm to a patient, malpractice lawsuits arise. Negligence is the concept of the liability concerning claims of medical malpractice, making this type of litigation part of tort law. Tort law provides that one person may litigate negligence to recover damages for personal injury. Negligence laws are designed to deter careless behavior and also to

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

We’ve all heard the saying, “If it’s not documented, it didn’t happen.” While it is an age old saying, it reveals one of the biggest issues within healthcare. The issue is not just proper and accurate documentation, but having a documentation that can keep up with the rapidly shifting and changing landscape that is healthcare. “Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing.” (Recognizing the Value of Clinical Documentation Improvement, 2014).

For protecting you in a legal way, you need to follow established set of rules for documentation while knowing the way for documenting appropriately.

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

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 notes, physical findings as well as diagnoses. These were all kept in a filing cabinet where mostly anyone could obtain the files and have the patient’s information. If the patient was at a different facility these records would then have to be mailed over which is not the most secure way to transfer a patients personal health records. It was then evolved that records should now be made electronically. This is so that security and transmission of a patients record can be more reliable.

Medical malpractice claims have risen dramatically over the past 40 years alongside the financial claim awards (Kessler, 2011). Currently, America’s medical tort system is regulated and enforced primarily by the states (“Medical Tort System,” 2016). The main focus of tort law is to preserve the peace between two parties, to determine fault and discourage wrong doing (Pozgar, 2016). Most physicians today carry medical malpractice insurance to protect themselves from the high defense costs of claims and potential financial awards (Kessler, 2011). As the number of medical claims increase and jury awarded punitive damage skyrocket, medical malpractice insurance premiums have also risen dramatically (Kessler, 2011). Malpractice insurance

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

Medical records are of significant importance to each and every patient. Patients have the right to receive care in a medical facility and not have their procedure of diagnosis released to unauthorized people. Medical facilities must protect the rights of each patient and their confidentiality by law. Records must be maintained accurately so as to respect the patient and not have inaccurate information released to any other provider. For example, it would be catastrophic to an actor’s career if it were to leak that they had human immunodeficiency virus (HIV) and in fact they really did not. Other actors or actresses may have performed with them and panic or even bring a law suit against them. It is important that records are maintained accurately

When the electronic health record is coded, it can be utilized for trending, alerts (warnings or signs), health maintenance, and decision support. It can be recognized correctly and electronically distinguished by way of the computer. Document image data must have an individual to look at and understand the information. Also, codes remove uncertainties about the physician’s meaning and diagnosis. It’s very crucial and essential to document a code acknowledging the clinical data as well as to the explanation of the text. A documentation is referred to as codified when the code is saved in the patient’s electronic health record. A codified electronic health record is more beneficial because it classifies the medical provider’s results or treatments.

The idea of electronic records is relatively new, and electronic patient consent also falls into that category. The goal of this type of consent is to make sure that patients can get the treatment they need quickly and efficiently, and that any hospital or doctor can access the records in that same manner. That way, patients get what they need and doctors are not as pushed for time and information. That allows them to better help their patients and save more lives. Addressed here are three methods for electronic patient consent. While this is part of a patient's medical records, it does not comprise all of their records or all of the methods that could be used to create those records. Instead, it is focused on the patient giving consent for a procedure or other event, and how doing so electronically (and storing that information in the same way) can help any medical provider address issues of speed, confidentiality, and everything else that goes along with medical care.

“Stay out of court with proper documentation,” by Sally Austin, is a great eye-opener to how crucial it is to document in the health care field as a nurse. As many know, nurses are extremely busy throughout their day, and as a result, many of them find it difficult to find the time to document in their patient’s medical record. According to the article, “a medical record is a legal document required by law and other regulatory bodies.” Therefore, it must be done so the patient gets the best and most accurate care. The medical record is also one of the first places people look when a lawsuit is brought up or something goes wrong, so documentation needs to be done properly and in a timely manner. The article gives five suggestions on how to avoid errors and complications in documentation which are: “be objective, document at the same time as your