QCAT Report: Notation In Healthcare

Practice: review, plan and monitor, eg respect for the value base of care, professional interactions with

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

* The registrar should also be granted access to the surgeon’s office notes to review any demographic information. This will ensure consistency and identification of information that may not have been documented during the surgical check-in process.

You are letting the provider know what the patient chief complaint or reasoning is to be seen at the office that day. All information the patient has prior will be beneficial for the process of the claim.

The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).

As a biller or coder, if it is not documented, it didn't happen that needs to follow to be able to give an excellent service to every patients. Documentation is the key to have an appropriate health patients result including demographics, health issues, and billing. “Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care. This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards.” If not documented that is not necessary to give any further diagnosis

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:

The patient has the right to receive information necessary to give informed consent prior to the start of any procedure or treatment.

The elements of the principles of confidentiality can be broken down into four separate categories: (1) Information provided by the patient is kept confidential unless consent from the patient has otherwise been given—unless it has direct legal implications or endangers the general public. (2) Informed Consent: is given freely, because the correct information has been supplied and the patient has sufficient information on the impacts involved. Information is otherwise given out on a need to know basis. (3) Duty of Care: Information is given out in order to protect the safety and health of others and the patient. Legal and general public health fall under this category. (4) Documenting Decisions: Consultations and actions that lead to

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

-Documented patient information, including medical histories, neurological deficits, and exam results, to present to the head ER physician for use in determining subsequent steps

They need to be able to explore sensitively and serious issues that boarders on informed consent with the patient. This is extremely important because there are patients currently receiving medications and medical treatments for different conditions for which they have not expressively given their consent either because they lack the capacity and/or understanding to do so. Also, it is very important that all medical professional (multi-disciplinary) involved in the patients care are contacted for any pertinent information. This will assure that all necessary assessments are considered and a clear rational can be defined, reviewed, agreed and documented prior to the informed consent being signed by the patient. This process will always help ensure that the medical professional is covering the agency and himself from any legal actions that could arise from the medical

     Documentation is the means by which we communicate our treatment to other health professionals and third party payers. In most cases, it is necessary to communicate effectively to others, orally and in writing the status of the patient. In addition, documentation is an important aspect of our field because it conveys the status and condition of the patient and our plan and evaluation of said condition to other caregivers. Medical records will be read by the doctors, nurses and in some cases by those submitting payment to the insurance companies. It is important that as occupational therapy students we develop documentation skills early and continue to refine these skills throughout our careers.

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.