Clinical Documentation To Help In Achieving Quality Care
Nowadays, people in the medical profession are finding ways to reduce errors committed regarding diagnosis and treatments being given to patients in the hospital. One method which has emerged and is still a topic of controversy today is clinical documentation. Clinical documentation is a form of electronic record that uses computers visualized to contain all the information needed on patients. This will provide the medical team with records, past and present, which they can review for them to able to come up with proper diagnosis and treatment. However, this method is still in the process of improvement.
Clinical documentation requires a specific person who is highly trained in this field to ensure the effectiveness of its use. There has to be a clear communication between the person and the medical team in order for the documentation to be accurate and precise. Documentation is very important in the medical field for the team to be able to work as one. Without it, there will be no precise source to use in order for them to customize the care to be given to the patient. You will not be just wearing those fancy cherokee scrubs or landau 7502 at work, you need to keep up and promote effective health care.
What important information is needed for a concise documentation?
There has to be a record of a complete assessment of the patient including physical and psychological tests, laboratories and other diagnostic tests. This will serve as baseline for determining what has improved or what has worsened since the day of consultation or admission.
A complete history of the patient must also be provided. Records of previous illness, hospitalizations, and other past medical history entries together with family history of certain diseases help in providing correct diagnosis as well.
Problem lists or a list of subjective and objective cues that have been reported by the patient or seen by the medical team and the corresponding actions done as a response to this are also part of the documentation. This will include diagnoses which have been formulated according to the signs and symptoms that the patient presented.
Treatment that has been chosen according to the assessment and diagnoses will include information on the medications, complete with the dosage, frequency, adverse reactions noted, response of the patient and compliance.
Tests and check-ups which work as follow-up to the condition of the patient is also involved. During the time of hospitalization and consultation, the medical team may request further tests to be done to identify improvement or worsening of the symptoms.
The response of the patient to the treatment and feedbacks of the other members of the medical team are essential parts in the documentation since one of the goals of this method is to provide a line of communication to the people involved.
As of the moment software programs and modifications are being done to improve this method’s efficiency and effectiveness. However, there are certain problems as of the moment. The method requires tools and trained personnel to make it work. Not all medical settings are able to come up with this technology yet and it might take some time before they do. When this method is improved and becomes available, it can be of big help in the documentation and records of patients for the medical team to use.
Clinical documentation requires a specific person who is highly trained in this field to ensure the effectiveness of its use. There has to be a clear communication between the person and the medical team in order for the documentation to be accurate and precise. Documentation is very important in the medical field for the team to be able to work as one. Without it, there will be no precise source to use in order for them to customize the care to be given to the patient. You will not be just wearing those fancy cherokee scrubs or landau 7502 at work, you need to keep up and promote effective health care.
What important information is needed for a concise documentation?
There has to be a record of a complete assessment of the patient including physical and psychological tests, laboratories and other diagnostic tests. This will serve as baseline for determining what has improved or what has worsened since the day of consultation or admission.
A complete history of the patient must also be provided. Records of previous illness, hospitalizations, and other past medical history entries together with family history of certain diseases help in providing correct diagnosis as well.
Problem lists or a list of subjective and objective cues that have been reported by the patient or seen by the medical team and the corresponding actions done as a response to this are also part of the documentation. This will include diagnoses which have been formulated according to the signs and symptoms that the patient presented.
Treatment that has been chosen according to the assessment and diagnoses will include information on the medications, complete with the dosage, frequency, adverse reactions noted, response of the patient and compliance.
Tests and check-ups which work as follow-up to the condition of the patient is also involved. During the time of hospitalization and consultation, the medical team may request further tests to be done to identify improvement or worsening of the symptoms.
The response of the patient to the treatment and feedbacks of the other members of the medical team are essential parts in the documentation since one of the goals of this method is to provide a line of communication to the people involved.
As of the moment software programs and modifications are being done to improve this method’s efficiency and effectiveness. However, there are certain problems as of the moment. The method requires tools and trained personnel to make it work. Not all medical settings are able to come up with this technology yet and it might take some time before they do. When this method is improved and becomes available, it can be of big help in the documentation and records of patients for the medical team to use.
