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Communication methods in healthcare
Importance of health records
Communication methods in healthcare
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It is important for the medical staff to make sure all the documentation is complete and through. Since documentation is one of the most important part of the medical practice and compliance. It must be stored correctly. The medical records can be used in noncompliance cases if they are created. All sorts of claims can be investigated by the federal government even if it’s a small mistake or it is fraud. The staff has to know what the compliance plan is and be trained on it otherwise they could end up breaking it and being noncompliant without knowing. The staff has to be able to communicate effectively, be able to keep the privacy of all the patients, code properly, make sure to keep proper patient care, staying up to date on regulations,
The Hospitals medical staff including on call- physician and their designees should be made aware of Hospital bylaws or policies and procedures.
Under HIPAA, are you legally allowed to view this patient’s medical information? Why or why not?
... of potential threats such as unauthorized access of the patient information. Health care leaders must always remind their employees that casual review for personal interest of patients ' protected health information is unacceptable and against the law just like what happened in the UCLA health systems case (Fiske, 2011). Health care organizations need clear policies and procedures to prevent, detect, contain, and correct security violations. Through policies and procedures, entities covered under HIPAA must reasonably restrict access to patient information to only those employees with a valid reason to view the information and must sanction any employee who is found to have violated these policies.In addition, it is critical that health care organizations should implement awareness and training programs for all members of its workforce (Wager, Lee, & Glaser, 2013).
US Congress created the HIPAA bill in 1996 because of public concern about how their private information was being used. It is the Health Insurance Portability and Accountability Act, which Congress created to protect confidentiality, privacy and security of patient information. It was also for health care documents to be passed electronically. HIPAA is a privacy rule, which gives patients control over their health information. Patients have to give permission any health care provider can disclose any information placed in the individual’s medical records. It helps limit protected health information (PHI) to minimize the chance of inappropriate disclosure. It establishes national-level standards that healthcare providers must comply with and strictly investigates compliance related issues while holding violators to civil or criminal penalties if they violate the privacy of a person’s PHI. HIPAA also has boundaries for using and disclosing health records by covered entities; a healthcare provider, health plan, and health care clearinghouse. It also supports the cause of disclosing PHI without a person’s consent for individual healthcare needs, public benefit and national interests. The portability part of HIPAA guarantees patient’s health insurance to employees after losing a job, making sure health insurance providers can’t discriminate against people because of health status or pre-existing condition, and keeps their files safe while being sent electronically. The Privacy Rule protects individual’s health information and requires medical providers to get consent for the release of any medical information and explain how private health records are protected. It also allows patients to receive their medical records from any...
CLIA is matter and it's design to improved the quality of clinical laboratory testing to the patients for safety and assurance that the healthcare facility will provide the best services to every individual. Each laboratory must have a certified to perform test and must follow written procedures to be able to give a positive and outstanding outcome. http://www.cdc.gov/mmwr/preview/mmwrhtml/00016177.htm
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
When educating our patients it is important to make sure that all education is documented. Documentation of all patient education is important because this will provide legal record for the nurse. It is also important in documentation that this will validate that all standards of care are being met. The Joint Commission will review charts and audit for the proper documentation such as patient education. The result of proper charting will provide reimbursement for the hospital, along with creating a safe environment for the patients. When it comes to the Joint Commission it also brings importance to tactics for patients with low literacy. As part of making care patient-centered, healthy literacy comes into play. When documenting this is an area that nurses have accountability for in order to create a safe learning environment. There is a high rate of medical errors and adverse events related to communication breakdowns, now widely recognized, are also widely acknowledged to be untenable (Edwards). The Joint Commission allows for guidelines to establish patient-centered care in order to create the best outcomes for
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
The first professional organizational standard chosen is the ANA Position Statement on electronic health record. Statement of ANA Position: The ANA believes that the public has a right to expect that health data and healthcare information will be centered on patient safety and improved outcomes throughout all segments of the healthcare system and the data and information will be accurately and efficiently collected, recorded, protected, stored, utilized, analyzed, and reported. Principles of privacy, confidentiality, and security cannot be compromised as the industry creates and implements interoperable and integrated healthcare information technology systems and solutions to convert from paper-based media for documentation and healthcare
Healthcare professionals in the medical office should be friendly and open. Patients entering the medical office should be greeted immediately with a smile and having a gentle touch also let the patient know you care. “Healthcare professionals in a medical office are held to a higher standard than most professions because they are dealing with the dignity of patients and the ability to be healed” (Wolff). Educating the staff to be professional in the medical office represents the office as being excellent in patient care. Patient-centered care success is required by the whole office which is treatment and patient experience, from the time they enter the office until they leave.
In this experience I learned to always keep patients safety as my priority and how important it is to advocate for them. It is important to check paper work even though it is time consuming for the nurse, however it prevents any medical errors from happening. Many times doctors and anesthesiologist want to continue with surgeries because they do not want to schedule the patients for a different time, but there are times patient cannot receive the procedure due to eating, glucose, or potassium levels being out of range and this cases the nurses advocates by giving her opinion and protecting the patient.
Fist I would like to talk about importance of medical record in case of law suit. The legal system trusts mainly on documentary which are sign. In a charge of negligence, very often the most important are the record which can proof the action doctor took. With the increasing use of medical insurance for usage, the insurance companies also need proper record keeping, to prove the patient 's request for medical expenses. Improper record keeping can result in decreasing medical claims. It is scary to note that in spite of knowing the importance of proper record keeping is still in a promising stage. It is wise to remember that “Poor records mean poor defense, no records mean no defense”- this can be consider as a golden rule of medical records. Medical records contain a diversity of documentation of patient 's history, clinical results, diagnostic test results, preoperative care, procedure notes, postoperative attention, and daily notes of a patient 's progress and medications. A properly obtained consent will go a long way in demonstrating that the procedures were directed with the agreement of the patient. A correctly written working note can protect a doctor in case of
Analyze the impact of poor documentation in patient care? Give one or two examples. Explain possible legal concerns for poor documentation.
The principles of documentation is clear, confidential, accurate, complete and concise, objective, organized and timely. Using documentation nurses are required to legally and ethically keep all information in the patient record confidential. There is the Health Insurance Portability and Accountability Act, known as HIPAA, which helps gives patients a greater control over their health care record (). Precise measurements and times must be used as much as possible. Accuracy can be enhanced through point of care documentation (Craven, 2017). The accuracy of documentation can be view from three perspectives veridical reflection of nursing, comprehensive while through detail of a patient journey and finally clarity in usage terms (Britain Summer of Nursing). The accuracy part is the really vital part in documentation within nursing because it shows the complete reflection of the stages of care that was provided by the health care professionals to an individual. Next, when an individual is documenting it needs to be complete and concise and organized. Having the report done as so allows for any health professional to find any information quick as possible without having to search throughout the entire chart for answers. When reporting it needs to be in a chronical flow order of the information about the patient care and procedures being done, within the chronological