Healthcare Documentation: Standards and Regulations

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Healthcare Documentation: Standards and Regulations

Health care facilities manage patients life and health daily; quality medical care relies on ably trained nurses and doctors, high facility equipment, and good record keeping. Health care documentation records the facts about a patients health involving both past and most recent examinations, tests, illnesses, treatments, medical records. Medical patient care, an important aspect, was contributing to high-quality care. Documentation provides the physician with a patients record history and any other details that they might not remember between the patients visits. A well updated medical document can help reduce a lot of inconveniences that may occur.

Health care documentation emphasizes five factors that significantly contribute to the documented informations quality and usefulness; these factors include accuracy, completeness, relevance, confidentiality, and timeliness. A health care facility must maintain the contents required for the legal health records and the documents content standards and integrity. Medical records facilitate doctors and nurses ability to assess and plan for patients required treatment and monitor their health progress over time. They also facilitate communication and continuity among doctors and nurses.

An excellent medical record should be accurate; information entered in the medical history is relied upon for accuracy throughout the patients life. If they visit another health care facility, those physicians will refer to the previous medical document (American Health Information Management Association, 2021). Inaccuracies in the medical report may result in getting improper medical advice, therefore, causing adverse healthcare problems that may result in a lawsuit for the physician or the health care facility. Medical records should also be relevant; this is important as the medical document contains information on a patients health. Adding inappropriate and non-relevant information may cause damaging legal complications.

All medical records should be time-cautious; for instance, physicians should file all the patients all information within twenty-four hours of admission. The medical records should be updated within seven days of being discharged. The documents should remain confidential, and any medical records are to be hidden; a patients information should not be left exposed to everyone. Any papers that are not relevant but contain a piece of patient information should be shredded. The facilities should not release any information about their patients health without their consent.

Factors Involved in Regulations About Paper and Electronic Health Records

An electronic health record is a medical record containing all the patients relevant information in a digital format. Healthcare facilities are implementing electronic health records because they hold some advantage over the hard copy files as they increase access to health care. EHR is available in most countries. However, there are still a few hurdles it has to pass before it can be entirely accepted and successfully implemented. confidentiality concern is one of the factors; it is the extent to which doctors and nurses believe using the system would risk patient information confidentiality. Furthermore, physicians are worried that unauthorized parties may find a way to access their patients health records hence the delayed implementation of the system in some regions.

Compare Standards and Regulations for Health Care

Quality standards prioritize specific areas for quality improvement the social health care. On the other hand, regulations protect the public from various health risks while offering countless programs for the peoples health and welfare. Healthcare regulations are necessary to ensure tractability and safe health care to anyone who can access the system. Regulatory agencies are keen on the facilities and practitioners, provide the public with information on changes in the industry, promote safety, and ensure legal compliance and quality services are offered.

Reference

American Health Information Management Association. (2021) Healthcare. Web.

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