Documentation Of An Accurate Medical Record - 928 Words

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care. Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met. Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the rightShow MoreRelatedClinical Documentation Improvement1293 Words   |  6 PagesIntroduction The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and careRead MoreEvaluation Of A Study Done By Jackie Mocygemba And Susan Fenton775 Words   |  4 Pages(2012) the clinical documentation in inpatient care to see if it uses enough detail for ICD-10. Since ICD-10 is a coding system that uses much more detail than others, it is expected to improve the ability to analyze clinical and cost data (Mocygemba et al., 2012). With the increased specificity of the coding system, the purpose of the study was to see if the clinical documentation is detailed enough. The pil ot study was cross-sectional and it used a variety of about 500 records that were coded usingRead MoreHistory Of Evaluation And Management ( E / M ) Codes1482 Words   |  6 PagesEvaluation and Management (E/M) Codes Accurate and comprehensible medical records documents are crucial for a positive outcome for the patient and health care providers. Health records sequentially convey significant details concerning patient’s health history and future care plans. These records are pertinent when initiating care in the acute and chronic setting for the patient. Medicare, Medicaid, and other personal health care providers necessitate rational documentation to guarantee that a procedureRead MoreA Brief Note On The Electronic Health Records Essay1484 Words   |  6 PagesClinical documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technolog y that helps maintain patient’s privacy. Both computers and EHRs canRead MoreThe Electronic Health Records ( Ehrs ) Essay1644 Words   |  7 PagesClinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patientRead MoreStrategies Of Nursing Documentation For Promote Patient Safety1498 Words   |  6 PagesStrategies of Nursing Documentation to Promote Patient Safety Introduction 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 accountableRead MoreLack Of Meticulous Documentation And Positive Patient Interactions Deter A Lawsuit Essay1272 Words   |  6 PagesIn the medical field there is an â€Å"age old saying, â€Å"if it is not documented in the medical record then it did not happen† the reality is, much happens that does not get documented† (Crozer-Keystone Health System, 2009, Para. 1). The question is, without documentation in the medical record, is the record complete, accurate, and concise? This is the question that everyone is asking in regards to the cou rt system, without documentation is it malpractice or should physicians be able to document whatRead MoreImpact Of Technology On Health Care780 Words   |  4 Pagesthem even more appealing. Past critiques of mobile health records were based on information security. mHealth responds to these critiques by incorporating advanced security on information transfer protocols; and by limiting the application to critical tasks, allowing it to function as a compliment to desktop application rather than standalone. The amelioration in care processes results to the financial benefit mHealth brings to the medical institution. With this communication means, provision of careRead MoreThe American Health Information Management Association1383 Words   |  6 Pagesrespected authority for professional education and training in the effective management of health data and medical records needed to deliver quality healthcare to the public. Throughout AHIMA’s history back to 1928, the American College of Surgeons established the Association of Record Librarians of North America (ARNLA) to â€Å"elevate the standards of clinical records in hospitals and other medical institutions† (www.ahima.org, 2015). Since its formation, the Association has undergone several name changesRead MoreElectronic Information At The Bedside, And Barcode Scanning Essay1606 Words   |  7 Pagesindividuals, as well as the aging population, the medical industry has had to be more meticulous in improving nursing care and ultimately patient safety. Technological advancements such as the electronic health record (EHR), the electronic medical administration record (EMAR), and a handheld device used for scanning patient armbands and medications were all introduced around 2007, and have facilitated the ability of nursing staff to promote effective documentation, verification, and overall, communication