Medical Records Is Responsible For Scheduling And Appointments

Unlike the MA job duties, nurses’ roles and responsibilities are different from the MA. The nurse are responsible to do phone calls to and from patient, faculty, doctor and other staff members all day long. They help manage day-to-day operations of the health care clinic, maintain health records, documenting each patient contact and updating patient profiles, ensure confidentiality during visits and telephone contact, distribute non-prescription medication after appropriate assessment, encourage health maintenance and promotion through counseling and awareness activities and assure that patients understand instructions.

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

Registered nurses work alongside physicians providing patient care in a variety of ways. A few examples of what nurses are responsible for include: administering medications, tracking patient’s vital signs, helping to diagnose and properly treat patient aliments and educating the patient and their family on their condition and the course of treatment. Depending on what area of medicine a nurse works in will determine more generalized and specific duties and responsibilities. There are many different areas a nurse may work in. Some areas include: obstetrics and gynecology, pediatrics, emergency room, and many more. Nurses can work in a variety of settings, these can include: hospitals, urgent cares, doctors office, nursing homes and home health.

Preadmission for example, in a nursing home is done by the manager, the patient’s GP or multidisciplinary hospital staff. It is the nurses or receptionist’s job to take the patient’s information and pass it on to the multidisciplinary team. Managers have the job of overviewing the situation. Discharges are granted by the doctor, social worker, occupational therapist or multidisciplinary team. The domestic assistant cleans the room before and after a patient, they also

Registered nurses have several duties and responsibilities that can range depending on the organization that they work for. Registered Nurse’s may be employed in physicians' offices, schools, hospitals, assisted living facilities, nursing homes, clinics, and even in prison settings. They are responsible to provide direct care to patients that are done under the order and supervision of a licensed health professional. The licensed healthcare professionals include physicians, nurse practitioners or physician's assistants. The daily actions of an RN may include receiving a patient assignment, assessment of each patient, administering medications, attending to patient needs, facilitating patient, assisting the physician with bedside procedures, monitoring laboratory results, and monitoring for any changes in condition. While on the job they might also encounter heavy lifting of patients, exposure to bodily fluids, and large amounts of time on feet. The amounts of hours they work depend on where they work. For example, hospital-based nurses mostly work a total of 3 twelve-hour shifts per week while a office-based nurse usually works 5 days a week for a total of 40 hours.

LPN’s carry out the orders of the physician, by administering medications and treatments to the patients assigned to them. LPN’s are often the voice of the doctor when it comes to patients care. LPN’s want to make sure to safe and effective care is rendered to all their patients. LPN’s often participate in readjusting a patient plan of care to benefit the patient’s outcome and their safety. LPN’s can delegate procedures to personal qualified to carry out those tasks. Some of these tasks may include items such as vital signs, glucose checks, back massages, bathing and ADL’s, activities and feeding of patients. CNA’s, play a very important role, in helping the nursing staff carry out their orders and duties every day the come to work.

The nurse has the ability to access the patient record at the bedside and have all of the patient information including x-rays, labs, notes at one time.

Nurse practitioners work with other doctors to ensure that patients stay healthy or become healthier once again. Due to their training in clinical medicine, nurse practitioners are able to make diagnoses and treat patients for many different health problems (Family Nurse Practitioner (FNP), n.d.). Although nurse practitioners are not doctors, they are advanced registered nurses. The description of duties that are expected of a nurse practitioner are as followed: developing treatment plans for different conditions, educating patients on proper healthy habits, conduct exams, preform different tests and exams, caring for patients and helping prevent further sickness,

Some duties will be conducting physical exams, making urgent care visits, prescribing medications and providing preventative care to residents. Providing education to families and staff education, attending care plan meetings to ensure quality care is received is also a role of an NP. Adequate documentation for billing Medicare and Medicaid or private insurance for reimbursement of services provided, is an ongoing process for both the physician and facility for payment and an NP could make the process

These duties are divided into administrative and clinical duties. In the administrative side, medical assistants answer phone calls, book appointments for outpatients, handle medical records, and billings. For example, if a patient calls to schedule an ultrasound, the medical assistant answers the call and books the appointment for the outpatient. Another scenario is if an outpatient changed their address, the medical assistant can update it on their medical record. Of course performing these administrative duties depends on the office they work at because the location and state law determine their duty limits and boundaries (AAMA, 2014). Medical assistants also have clinical duties meaning hands-on responsibilities. Medical assistants can discuss the preparation processes of treatment to patients, they could give the green-light for medication refills, perform electrocardiograms (EKGs), draw blood and perform other basic laboratory procedures (AAMA, 2014). For example, if a patient’s physician suspects a case of gastralgia, they would request a urine/feces sample and or blood drawn in which the medical assistant is responsible in performing. Also, medical assistants can also administer medications such as insulin if a patient has diabetes or nitroglycerin if the patient has a history of angiostenosis or

Registered nurses monitor records and report changes in patient’s symptoms. RN’s have to check vital signs, diets and physical activities on their patients daily. RN’s have to observe patients and monitor their overall health daily in some cases every few hours. They authoritatively inform individuals, families, and health groups on inculcation for patients. RN’s coordinates with other health care professionals to customize care plans for patients. Registered Nurses prepare patients for treatments and examinations. RN’s supervise other healthcare personnel such as an LVN (License Vocational Nurses) and CNA (Certified Nurse Assistants).

The nurse practitioner is responsible for patient management. Certified by American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners, NP have specialized training and education to qualify them to work directly with patients independently or collaboratively with other NPs and physicians. They also provide preventive and acute nursing care services to individuals of all ages. The NP has the ability to supervise, provide patient educate, supervise or administrative duties due to having their own patients, depending on the state of which one lives. They also have to know a little bit about informatics as well since some do run their own clinics and have to know how their computer

Registered Nurses perform a variety of duties that include but are not limited to performing physical exams, & acquiring medical histories. Nurses also provide health counseling and education as well as administer medications, wound care, and other interventions. Nurses are responsible for coordinating care in collaboration with other health care professionals and interpret patient information and make decisions about actions needed. Nurses are also responsible for supervising the care provided by other health care professionals such as LPN’s, technicians, etc.

A physician directs your treatment at the hospital. Doctors can easily access patient information, test/lab results, and send out E- prescriptions to pharmacies. Registered nurses wear navy blue and white scrubs. They are responsible for planning, coordinating and providing for a patient’s care. They use the information system daily to update, evaluate and record patient symptoms, review patient treatment plans and their measure progress. Other members of nurses that use the health system are licensed practical nurses, and student nurses. They are all managed by the RN and oversee all the patient care and activities. Allied health professionals wear tan and black scrubs. They perform diagnostic tests and therapy required for the care and treatment a patient needs. These allied health professional include laboratory staff, radiology techs, physical therapists, and respiratory therapists. “They may play roles in evaluating and assessing a patient’s needs, keeping the physician and others informed of the patient’s progress and caring for the patient” (Association, 2012). Clerical Assistants are volunteers at this hospital and does not provide care for patients but they do have access to information systems under the supervision of administrators. They answer telephones, proof-read, perform data entry, and sort

Documentation in the medical field is a vital component to providing quality care and maintaining a consistent care plan. There must be policies in place to protect proper documentation to maintain a high standard of care for patients. Documentation allows for a detailed history of care and displays methods that were successful to better direct the care plan of patients. Documentation provides structure for care plans, hospital policies are care plans for units to maintain order and provide structure for efficiency and high functionality. To maintain an optimally functioning unit there must be proper documentation for each patient, as well as policies that are enforced to keep documentation consistent,