The organization and security of a patient’s health information, which includes their symptoms, medical histories, test results, procedures, and diagnosis, is the function of health information management (HIM). HIM is significant for suppliers and other HIPPA elements to ensure information is secure and guarantee consistence with unofficial law. ” According to Kamil (2020), “the patient’s health care record is the primary medium of communication between health care professionals, assisting them in delivering a high quality of care.” In this assessment, I will discuss four distinct kinds of documentation that are utilized in a clinical or hospital setting.
Progress Notes
An advancement note is a continuous record itemizing sickness and therapy utilized in clinics EHR, facilities, and home medical services. Healthcare professionals keep records of the services they provide and the results of those services, as well as update other healthcare professionals who are treating the patient. When shifts change, progress notes ensure that team members receive the same level of care. Progress notes can be used as legal documentation in addition to keeping track of medical history and care. The patient’s name, date/time, DOB, clinical assessment (vitals, pain, test results), any behavior changes, treatment plan changes, incidents, and follow-up instructions for further care are all included in a progress report. Nursing action that has been finished or that will happen ought to be appropriately archived. (” BMC Nursing: “Accurate documentation and reports play a pivotal role in health services” (Nursing care activities based on documentation). HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System
History and Physical (H&P)
The comprehensive assessment of a patient and the issue they face is the basis for health and physical documentation. Included are the actual test discoveries, interview with patient, and rundown of tests forthcoming or acquired. In order to identify issues and plan a course of action, this assessment is essential. H & P is utilized in all health care settings, including hospitals, clinics, home health care, hospice, etc. without it would be challenging to give care in light of need and assess result of care gave.
Operative Report
The patient’s medical record includes an operative report that details the surgical procedure. The report’s purpose is billing and documentation. The name of the surgeon, the current staff (assistants, nurses), the procedure that was carried out with a description, the results, the estimated blood loss, the specimens that were taken, and the post-operative diagnosis are all included in the report. A team member should finish the report as soon as possible after an operation. Clinicians and claim reviewers from a variety of backgrounds and experiences read the documentation; According to (Documentation in Health Care) (ASHA), “it is important that notes and reports are clear and legible and that they efficiently convey all the essential information that is required for clinical management and reimbursement.”
Discharge Summary
A discharge summary is a handover that explains why a patient was admitted and what happened during their time in the hospital. The summary ought to include the patient’s response to treatment at discharge, any follow-up plan, recommendations and instructions for home care, and any equipment requirements. The MD/DO or other qualified expert who has acknowledged responsibility for the patient during the patient’s visit to the emergency clinic, in accordance with state regulations and medical clinic strategy. As part of this responsibility, the discharge summary would be developed and entered. Would CDI experts be able to archive in the release outline at any time?, 2018)(ACDIS, 2018).
HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System
In conclusion, proper documentation improves patient safety and quality of care. Accurate documentation ensures that patients receive the appropriate consideration from all suppliers involved with their consideration and reduces risk exposure for patients. The patient’s outcomes can be negatively impacted by inadequate documentation or data loss. “90% of unanticipated events that resulted in death or serious physical or psychological injury to the patient that were not related to the patient’s illness were due to breakdowns in communication between health care professionals,” reads a 2005 report from Joint Commission International (JCI).
References
Asmirajanti M., Hamid A., & Hariyati RT. Nursing care activities based on documentation
BMC Nursing. 18, Article number:32 (2019).
Documentation in Health Care- ASHA
https://www.asha.org
Hariyati R, Delimayanti M. Widayatuti. Developing Prototype of The Nursing Management
Information System in Pukesmas and Hospital, Depok Indonesia. Bus Manag.
2011; 5 (22): 9051-8
Joint Commission International (JCI). Patient Safety; Essentials for Health Care. Oakbrook
Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005.
Kamil, H., Rachmah, R., Wardani, E., & Bjorvell, C. (2020). How to Optimize Integrated Patient
Progress Notes: A Multidisciplinary Focus Group Study in Indonesia. Journal of
Multidisciplinary Healthcare, 13, 1-8. https://doi,org/10.2147/JMDH.S229907
Q&A: Can CDI professionals document in the discharge summary? (2018). Volume 12, Issue 17
https://acdis.org
