Risk Management Nursing Documentation Nur 492

As nurses in the health care system, we are the one that is been looked upon with high expectation to provide safety and quality care. Even more the nurses that are present and future in the field of evidence base practice and nursing informatics. With this development knowledge, nursing are expected to perform at a certain level when it comes to engaging in electronic health record and patient care. Gone are the days where paper records was used because it doesn’t sufficiently meet the needs of the health care delivery system today.

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

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).

Risk management is about reducing the likelihood of errors with the aim of improving and monitoring the quality of health care services. The purpose for risk and quality management is to improve the care of the patients and reduce liability among the staff and the patients. In following risk and quality management protocols

The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result

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:

Nurses’ are to ensure patient safety in all aspects of care provided. Sometimes, this is found outside of what is considered “actual” care, such as a physical assessments and administration of medications. Every day nurses’ are given assignments to follow, which includes which patients to take care of. What happens when this assignment is unsafe for all involved? Administrative Codes have been established by each state Board of Nursing to guide nurses’ in different situations. Safe Harbor Peer Review assists nurses to know how to handle an unsafe assignment.

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

A typical day in the office includes auditing claims, sending claims to insurance companies, and working denials. Auditing claims is making sure what the physician coded for is documented and that the codes are correct. Each day I review the physician 's documentation against the codes they put into our system for their patient’s visit. At times when the documentation does not match what is coded, I query the physician and ask them to re-review their assessment and documentation. Below in the section, “Issues and How They Were Resolved” is a couple of examples of when the physician was contacted. I audit multiple claims a day and it is important that each one is suitable before it is sent to the insurance company.

Disclosure for direct patient care emphasizes the importance of limiting the exposure of health care information of a patient to only the one offering treatment. Although physicians are not required to receive their patient’s authorization, others healthcare workers, such as billers, coders, and front desk staff, are not allow to gain access to patient’s health information. In my opinion, this disclosure is essential to those whose careers are in the medical field. My mother is a registered nurse at the same hospital I was admitted to multiple of times for several unexpected emergencies. Although her coworkers shown concern, my personal information, lab results, and the treatments are confidential and only my mother and my physician are allow to see this private information. Several of years later, when I moved from New Jersey to Maryland, I felt comfortable having control of my health information by being asked to call my old physician to fax my health records to my new general physician. After calling, they also required my new physician to send a fax to them with my signature ensuring that my information is secured and only the new physician who is responsible for my care receives and reviews it. A

R.O. is a 43-year-old female Latino patient who has been living at home alone since she got divorced three months ago. She does not have any living or available family in the United States. She is the oldest of three children. Her parents died of an accident when she was little. Two of her sisters live in Mexico. She has lost contact with her family in Mexico when she got married and move to the United States. She also has stopped communicating with her ex husband since they got divorced. Although she does not have any support from her family, she states that her church member has been very supportive. Moreover, R.O. states she was a homemaker until the divorce. Currently, she has been working as a dishwasher near her house.

Paper charts can cause doubt when there is a lack in the signature, or when staff is unable to read related to illegible writing. Other issues can be; abbreviation and not timing and dating the entry contribute to inaccurate charting. Paper chart can lead to a lack of clarity with orders which can affect emergency care for critical patients. Paper charts limit the ability to prompt nurses to check on areas such as medication interactions and dosage contributing to poor patients’ outcomes. Paper charts of previous admission are kept in storage places, making it necessary to find these charts which can take time. This again delay patient care and could result in poor patient outcomes. Paper charts have an increase risk of improperly filed, leading to an increase threat of a lost chart. In a case of a medical emergency, this could be catastrophic for the patients. Another barrier is the inability for interdisciplinary members to view the paper chart. To view a paper chart, it will need to be scanned or emailed to the interested party, which again can delay treatment for the patient. The last point is, “over time paper charts will naturally deteriorate in storage” (Csiszar, J., & Media, D., n.d).

Proper documentation can mean the difference between receiving and not receiving reimbursement for services the physician performs (Andress, A. A. (2009). If the documentation is not recorded properly, billing codes cannot be entered correctly; this can cause a denial in payment or cause payments to be delayed. It can also cause a patient’s medical record to not have all the critical documentation needed for them to receive the best possible care. There is a requirement for documentation of quality medical care and the outcome of the care before being able to renew contracts with managed care organizations (MCO). Proper documentation also reduces liability for the medical office and reduces the chance of triggering an audit.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.