Correct ways of making health documentation

Question 1

Outline how a health professional can demonstrate respect when creating health documentation.

Answer 1

In order to demonstrate respect, the heath professional refers to the person/s rather than their condition (McDonald et al 2015). This requires use of person -centred expression to avoid devaluing or marginalising the person/s (American Psychological Association APA 2010).

Question 2

List three characteristics of a quality document.

Answer 2

1. Accuracy
2. Understandability
3. Well written
4. Professional

Question 3

What are six potential reasons for quality documents prepared in healthcare.

Answer 3

1. Provides record of services
2. Records details of interventions
3. Comparisons for past and present functions
4. Related outcomes of interventions
5. Recording appropriate measures of the outcomes
6. Ensures continuity of service

Question 4

What is health literacy?

Answer 4

The ability to easily find and interpret data to make informed decisions for a person/s health a wellbeing.

Question 5

State why it’s important to encourage health literacy.

Answer 5

It is important to eliminate as many barriers as possible when it comes to making informed decisions for someone’s health and wellbeing. By having easily accessible information presented succinctly and too the point. Health professionals can operate efficiently and knowledgeably.

Question 6

Explain why it’s important to consider the recipient of written/digital documents, whether they be colleague health professionals, other professionals or the person/s.

Answer 6

The recipient of the written document may influence the way that document is composed. For example documentation sent between health professionals may contain jargon related to their healthcare field. However documents sent to clients may be laid out in a more digestible manor containing minimal jargon so it is more easily understood.

Question 7

Suggest reasons for considering the privacy and confidentiality (ethical considerations) requirements of documentation.

Answer 7

Ethical requirements include consideration of confidentiality in order to protect the rights of the person/s. (Allan & Davidson 2013, Resnick & Soliman 2012, Scott 2006, Zonana 2011). This involves more than divulging names, it is also about protecting the identity of the person/s by not disclosing diagnoses or any other information (such as gender, age, address or locality) that might identify the person/s (Yap &Yang 2014)

Question 8

List what should always be recorded in a report or letter whether or not electronic.

Answer 8

1. The date
2. Identifying details of the person/s which may include name, identification number and/or address, age, gender, diagnosis and often reason for referral.
3. Well organised points can be pullet points, numbers or bold writing.
4. Use examples of needs to validate and verify the stated points (Higgs et al 2010)
5. Clear statement for each person and related action plans.
6. Contact details/signature of the health professional
7. Salutations
8. Statement for the reason of the letter in the first paragraph.
9. Concluding paragraph that indicates required future action or details of future events.
10. Sign off

Question 9

List the things to remember before sending a report or submitting an entry into a database.

Answer 9

1. Distinguish between fact and opinion in all written records (Allan & Grisso 2014).
2. Re read and correct any content, grammar and spelling mistakes.
3. Sign, date, PDF and file all reports and letters before sending them.