What should be included in patient documentation?
What should be documented
- The most current information.
- Clinically pertinent information.
- Rationale for decisions.
- Informed Consent discussions or the patient’s refusal of care.
- Discharge instructions.
- Follow-up plans.
- Patient complaints and response.
- Clinically pertinent telephone calls.
What are the 5 C’s of documentation?
Client’s Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality. Client’s Words – a medical assistant should always record the patient’s exact words. They shouldn’t rephrase or summarize the sentence. The exact words will help the physician make a more accurate diagnosis.
What are the seven criteria for high quality documentation?
There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality….Clinical Impact of CDI
- Clear.
- Consistent.
- Complete.
- Reliable.
- Legible.
- Precise.
- Timely.
What are the documentation standards?
Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production.
What is effective documentation in nursing?
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
What are the steps to effective medical record documentation?
Here are three steps you can take to ensure your records meet the needs of patients and your organization.
- Step 1: Set policy. Evaluate your documentation policy to ensure that it covers key points.
- Step 2: Educate staff.
- Step 3: Follow up.
- Do’s and dont’s.
- Protect your staff and your organization.
How do you maintain patient records?
Top 3 Ways to Track and Maintain Patient Records:
- Integrate Patient Records.
- Record Medical Prescriptions Electronically.
- Archive Patients Record on Cloud.
What is proper documentation in nursing?
Introduction. Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
What is proper documentation in healthcare?
Documentation typically reports why the patient was seen, what was done, what was found, and what was recommended in a way that justifies the assigned diagnosis and procedure codes (see Coding/Billing for Reimbursement). Health plans reviewing claims will ask for documentation to justify the services delivered.
What are examples of medical documentation?
– WBC 14,000 – Respiratory rate 24 – Temperature 102° F – Heart rate 120 – Hypotension – Altered mental status – IV antibiotic administration – IV fluid resuscitation
Why is physician documentation important?
Improved Patient Outcomes. Research has shown that keeping proper medical documentation improves a patient’s clinical outcome after he or she leaves the hospital.
What is a physician documentation?
When asking physicians why good clinical documentation is necessary, they will most likely say that it is to document the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health record.
What are examples of medical documents?
– Prompt documentation reduces the risk of you forgetting key details. – It ensures all other team members are aware of any changes to a patient’s condition or management plan. – In reality, this isn’t always possible.