Hai Resmy Case Study

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

2008). Another system focused on patient scheduling in a rehabilitation setting (Ozbolt, J.G., Saba, V.K. 2008). Nurses at a California hosptial assisted in developing the first comprehensive hospital information system and helped integrat the system for nursing care planning, documentation, and feedback (Ozbolt, J.G., Saba, V.K. 2008). They developed the standard care plans that are used throughout the world today (Ozbolt, J.G., Saba, V.K. 2008). Another big achievement of this decade was the introduction of the first commercial electronic medical record (Thede, L. 2012). This new system was patient-oriented and was implemented throughout the hospital (Thede, L. 2012).

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

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.

Keeping data on specific nursing sensitive indicators and making that information available to staff, would help raise awareness of the issues that need to be addressed. With the documented information provided it could empower the staff in patient safety and quality improvement efforts, something they have a direct impact on. By educating staff to be aware of potential issues it would help advance quality patient care. In this current case, pressure ulcers, the use of restraints and patient/family satisfaction could have been handled in a better way to improve patient satisfaction and outcomes. It’s possible that restraints might have not been necessary, the pressure ulcer may have been prevented and the patient and family would have felt that their needs were being met, and not neglected.

Quality patient care requires the communication of relevant information between health professionals and/or health systems. Healthcare professionals who regularly work with patients and their confidential medical records should contribute to the development of standards, policies, and laws that protect patient privacy and the confidentiality of health records/information.

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:

HIPAA requires nurses and nursing students to keep patients’ medical records confidential at all time. For instance, I used computer to review patient’s diagnosis, I made sure that I signed off the computer after using it. I also made sure that all the information I brought home with me did not include patient’s name and other information that identify patient identity.

In the Health Information Field people work with patient personal information all day long. If the system is lacking then that personal information could get out causing personal harm to a patient. The TJC has standards and is constantly checking the quality of the programs and security that the health facility implement.

For whatever reason we have a big population of Compass Group contracts that have the wrong billing date. This may be a migration error, either way I need these renewal to reflect the an end date of 01-JAN-2017 to align with the Compass Groups fiscal year.

When you look at how nursing documentation affects patient outcomes consider all the benefits of informatics. Electronic charting systems allows for automation in patient safety issues. This automation can be prompts that forces a nurse to address things like abuse history, and many other requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and if the nurses document, there is a history of abuse, the system can automatically send a referral to a department to follow up on the nurses charting. The clinical systems store valuable information, and re-populates, this information on later admissions. An example of this valuable information, would be a patient with the diagnosis of methicillin-resistant staph

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.

In all health care facilities it is crucial to keep clear and accurate record keeping. This is carried out as a professional duty of care by a registered nurse as it is an integral part of nursing and midwifery practice. Accurate record keeping ensures high standards and improves stability of care (Benbow, Jordan, and IVONNE, 2015, pp. 52-54). All records should be clearly written to enable any health care professional to know what is wrong with the patient, what treatment and care they may need or be receiving, their progress and their plan of care.

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.