QCAT Report: Notation In Healthcare

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.

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

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).

Documentation, a vital method for deciding the standard of care rendered to a patient to protect nursing action(nurse together,2010).This concurs with the ANMCs competency standard 1.1 where it expresses that 'Practices as per enactment influencing nursing practice and medicinal services'. Documentation is characterized as 'anything composed or printed used to outfit proof or data that is lawful or official' (Crisp&Taylor,2001). With documentation, medical caretakers can unmistakably portray the customer's present well being status and what meditations ought to be done and if the intercessions that were completed profited the customer. This concurs with a reference from Owen(2005) where it says that documentation ought to give verifiable, present, far reaching and reliable data about the appraisal and care of the patient.

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 information that should be obtained from the patient at the time of scheduling the appointment is the reason for the visit, name, DOB, phone number, and insurance information.

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,

Patient's name, address, telephone number, and date of birth. (In the case of a minor child, you will also need the name of the parent or guardian requesting the appointment).

accuracy, provide a systematic training to medical providers, nurses and general staff on the hospital protocol as well as Code of Ethics.

In health care, we should make note of patient`s condition on his chart well. Furthermore, we should keep the patient`s documentation with the patient.

     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.

The three areas of the tutorial I notice that I am confident in, is Communication on the tutorial on the Conduct Written Communication 1 explains that written communications is better because it provides evidence, including letters, forms, taxes, emails, telephone messages, orders, and instructions for patients. Also, for a written document verifies that you are correcting the document by grammar check and that the spelling is correct. When making a mistake on a written document it can affect the facility, and a mistake can lead the patients from receiving the wrong dosage this can be life- changing; therefore, that is why written documents are important. The Conduct Written Communication 2 demonstrates how to label a letter, which includes

Information that maybe abstracted active or standing orders, medication allergies, immunizations, patient history and problem lists, surgery history, and medications the patient is currently on (Labelle & Swaine, 2002). If the information remained in the

Mr. Thathamkulam has taken leadership in identifying ethical issues for the Telecare department to improve the delivery of care to patients and families. Mr. Thathamkulam has maintained privacy and confidentiality during assessments, thereby in protecting all paper and computer documentation. Mr. Thathamkulam advocates for the maintenance of patient confidentiality by keeping charts off the