Evaluation Of The Medical Patient Records - 944 Words

Documentation in the healthcare setting is the materials that provides official information or evidence that serves has a record. (Merriam-Webster Dictionary) Yesterday healthcare organizations depended on verbal and written reporting to serve as a tool for continuity of care for patients. The first standard of nursing that is taught in Nursing School is in Fundamentals of Nursing which is one standard of nursing practice, superb assessment having the ability to evaluate, gather and analysis a patient’s health status. A good assessment directly influences the nurses’ plan of care (Taylor, 2001) which is a necessity to provide good patient care. This is why nurses’ assessment should be conveying accurately. In Nursing the main factor is being the patients’ advocate, this will determine if the patient is receiving standard of care. Charting is essential for many reasons such as ensuring continuity of care, treatment plans for the patient, substantiate billing, and most important is to recollect memory or to justify care that was provided. Medical patient records are also organized documents that to obtain patient medical history and as well as previous care. Medical records are personal documents stored by his or her health care provider. Each medical record has enough information to distinguish each patient. It contains their first and last name with gender and age. This method of medical record is still in use by many physicians; however, there has been a faster andShow MoreRelatedWill The Ehr Increase Clinical Utility By Providing The Patients With Easy Data Accessibility?978 Words   |  4 Pagesproviding the patients with easy data accessibility? 2. Will the EHR allow users to see the course of disease in terms of activities and responsibilities? 3. Will the EHR allow users to monitor compliance in daily basis? 4. Will the EHR help in adjusting the course of chronic disease in a standardized program? These questions needs to be verified in order to establish the usefulness of the system. In short, when clinical simulation is to be carried out, the following steps can help in evaluation. VerbalRead MoreThe Importance Of The Cardiac System Of Care, The Healthcare And Evaluation Professionals From The State Of South Dakota1548 Words   |  7 Pagessystem of care and provide assistance to the emergency medical services (EMS) by equipping them with medical devices such as Automatic External Defibrillator’s (AED), mechanical CPR device LUCAS 2 and Simulation training support. 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This has been mainly on the development of the appropriate chip and other electronic storage systems that can hold the information about each Americans medical information and any other relevant data like the physical address and the migration trendRead MoreFederal Qualified Public Health Clinic1223 Words   |  5 PagesMany of FQPH patients are recipients of Medicaid and SCHIP, or uninsured self-pay clients as it is located in a large Northwestern City. The physicians are frustrated with current conditions. As a last-ditch effort, they inform Administrator of their complaints that need immediate attention or they will terminate employment. Those complaints include inadequate paper medical records; inefficient patient registration practices; mean and slow employees; mistreatment of patients and medical staff; inadequate