UNIT 5 GUIDELINES AND PROTOCOL IN DOCUMENTATION AND HEALTH CARE RECORDS

Question 1

is required to record pertinent facts, findings, and observations about a client’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.

Answer 1

Medical record documentation

Question 2

The ___ the care of the client and is an important element contributing to high quality care

Answer 2

medical record documents

Question 3

may serve as a legal document to verify the care provided.

Answer 3

Medical Records

Question 4

The medical record facilitates:

Answer 4

1. The ability of the physician and other healthcare professionals to evaluate and plan the client’s immediate treatment, and to monitor his/her healthcare over time.
2. Communication and continuity of care among physicians and other healthcare professionals involved in the client’s care.
3. Accurate and timely claims review and payment.
4. Appropriate utilization review and quality of care evaluations.
5. Collection of data that may be useful for research and education.

Question 5

With documentation of medical records, particular emphasis must be placed on the five factors that improve the quality and usefulness of documented information.

Answer 5

1. Accuracy
2. Relevance
3. Completeness
4. Timeliness
5. Confidentiality

Question 6

Documentation in health care records must comply with the following:

Answer 6

1. Be clear and accurate.
2. Legible and in English.
3. Use approved abbreviations and symbols.
4. Written in dark ink that is readily reproducible, legible, and difficult to erase and write over for paper based records.
5. Time of entry (using a 24-hour clock – hhmm).
6. Date of entry (using ddmmyy or ddmmyyyy).
7. Signed by the author, and include their printed name and designation. In a computerized system, this will require the use of an appropriate identification system eg. Electronic signature.
8. Entries by students involved in the care and treatment of a patient / client must be cosigned by the student’s supervising clinician.
9. Entries by different professional groups are integrated ie. there are not separate sections for each professional group.
10. Be accurate statements of clinical interactions between the patient / client and their significant others, and the health service relating to assessment; diagnosis; care planning;
11. Care or treatment provided and client response; professional advice sought and provided; observations.
12. Be sufficiently clear, structured and detailed to enable other members of the health care team to assume care of the patient / client or to provide ongoing service at any time.
13. Written in an objective way and not include demeaning or derogatory remarks.
14. Distinguish between what was observed or performed, what was reported by others as happening and / or professional opinion.
15. Made at the time of an event or as soon as possible afterwards. The time of writing must be distinguished from the time of an incident, event or observation being reported.
16. Be relevant to that patient / client.
17. Only include personal information about other people when relevant and necessary for the care and treatment of the patient / client.
18. Addendum – if an entry omits details any additional details must be documented next to the heading ‘Addendum’, including the date and time of the omitted event and the date and time of the addendum.
19. For hardcopy records, addendums must be appropriately integrated within the record and not documented on additional papers and / or attached to existing forms.
20. Written in error - all errors are must be appropriately corrected. No alteration and correction of records is to render information in the records illegible.

Question 7

if an entry omits details any additional details must be documented next to the heading ‘Addendum’, including the date and time of the omitted event and the date and time of the addendum.

Answer 7

Addendum –

Question 8

all errors are must be appropriately corrected. No alteration and correction of records is to render information in the records illegible.

Answer 8

Written in error -

Question 9

it is a comprehensive and strict privacy legislation which states that “to protect the fundamental human right of privacy, of communication while ensuring free flow of information to promote innovation and growth.”

Answer 9

Data Privacy Act of 2012

Question 10

. This comprrehensive privacy law also established a National Privacy Commission that enforces and oversees it and is endowed with rulemaking power.

Answer 10

Republic Act No. 10173

Question 11

It is also known as the Republic Act No. 10173

Answer 11

Data Privacy Act of 2012