Documentation in healthcare Medical Therapeutics

Medical Therapeutics Standard 10) Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through:  a. History and Physical including but not limited to: family, environmental, social, and mental history b. Brief Head to Toe Assessment noting normal vs. abnormal findings  c. Vital Signs Assessment (VS) d. Height/weight, BMI /Calculation e. Specimen Collection

Objectives Explain the importance of clinical documentation Provide principles of documentation Describe the contents of the medical record Discuss how documentation impacts quality of care, financial planning, healthcare outcomes and appropriate reimbursement

Documentation Matters!!

Contents of a hospital medical record History and Physical (admission note) Emergency room documentation (if any) Progress notes Nursing Notes Operative reports (if any) Medication record Flow charts Lab and radiology reports Orders Discharge summary

Why is documentation important, anyway? Documentation is critical for patient care Serves as a legal document against claims of negligence, improper treatment or omission of care Provides evidence for quality reviews Validates the patient care provided Impacts coding, billing, and reimbursement

Principles of documentation Complete and legible All entries should be dated and authenticated by provider Documentation of each patient encounter Date and reason for encounter Appropriate history and physical including any present problem Assessment and plan of care Explanation of treatment Any other relevant information

In a nut-shell Clinical documentation should be: Complete Legible Timely Concise Clear Patient Centered Accurate

REMEMBER:

How do we use this information? Applying what you learn. Each group will research the documentation requirement and styles of an assigned therapeutics career. Create a PowerPoint summarizing your information to present to the class Demonstrate application of proper documentation techniques researched by creating a situation in which you would document using the researched style. Create a chart entry using your researched style to turn in to Ms. Corbin