Medical record and clinical documentation

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Medical record and clinical documentation により Mind Map: Medical record and clinical documentation

1. Guidelines

1.1. Purpose of Guidelines: Purpose of Guidelines support employers, policy makers, managers and clinical staff in documentation practices and policies

1.1.1. Documentation practices and policies that demonstrate -the professional obligation -accountability - legal requirements to communicate patient health information and clinical interventions in the public interest. ((It should be assumed that any and all clinical documentation will be scrutinized at some point.))

2. Professional documentation

2.1. Purpose of Professional Documentation:

2.1.1. 1-Communication> is the basis for communication between health professionals.

2.1.2. 2-Accountability> Documentation demonstrates the clinician’s accountability and records their professional practice. may be used in relation to -performance management -internal organisational inquiries and/or legal proceedings (such as civil lawsuits or coronial inquests).

2.1.3. 3-Legislative requirements> Nurses and midwives are required to make and keep records of their professional practice in accordance with standards of practice of their profession and organisational policy and procedure. may be found to constitute unprofessional conduct by a regulatory authority when - Failure to keep and maintain certain documentation records as required - falsifying documentation - incomplete or inaccurate documentation - signing or issuing a document that the person knows or suspects to be false or misleading

2.1.4. 4-Quality improvement> may be used to evaluate professional practice as a part of quality assurance mechanisms

2.1.5. 5-Research> is a valuable source of data for health researchers is provide information in relation to -clinical interventions -evaluates patient outcomes -patient care

2.1.6. 6-Funding and resource management> Accurate and comprehensive documentation of interventions provides a valuable source of evidence and rationale for funding and resource management.

2.2. Professional documentation includes: - Written health record -electronic health records -audio and videotapes -Emails, facsimiles -images (photographs and diagrams) -observation charts -Check lists -communication books -shift/management reports -Incident reports -clinical anecdotal notes or personal reflections Other documentation Other documentation may be relevant to: -Evidence of clinical practice and of interest to the employer -regulatory authority - The Ministry of Health, courts -funding body or the general public. Other documentation not directly related to the patient includes: -Policies, procedures and protocols -critical incident / occupational health and safety reports - Statistical and research data - reports related to service and funding agreements -staffing rosters -Personnel files -performance appraisals -clinical assessments -published reports/papers

3. Maintaining quality documentation practice

3.1. organizational support:

3.1.1. .effective systems to support accurate and concise documentation .appropriate policies and procedures .risk management strategies .the provision of adequate time allocation

3.2. leadership:

3.2.1. encouragement of clinical staff to be involved in decision making .implementing quality implement processes .promotion of documentation as an integral part of practice and professional responsibility

3.3. resources:

3.3.1. access to an appropriate physical environment .reliable, accessible and appropriately maintained equipment .documentation systems appropriate to/for the setting in which the care occurs

3.4. -professional development:

3.4.1. appropriate information and education for the staff .performance management processes

3.5. -communication system:

3.5.1. documentation systems that promote appropriate sharing of information .effective exchange of information with confidentiality .integrated progress notes .secure electronic data .appropriate processes for patients to access information in relation to their care

3.6. -responsive to action:

3.6.1. .documentation systems that are responsive to change .accommodate changing patient population needs

4. Documentation policy

4.1. clarify:- -legislative requirements -minimum requirements -format and type -roles and responsibilities of the clinical staff -accepted abbreviations -requirements for witnessing or counter signing documentation -requirements for access, storing,archiving and retaining documentation -requirements for documentation of verbal orders and provision of telephone advice -requirements for confidentiality and privacy

4.2. Monitoring for documentation:

4.2.1. An audit process will play an important role in monitoring quality and standard of care and the ability to produce accurate and complete coded data.the need to maintain confidentiality of patient information equally applies to documentation audit processes.

4.2.2. review of the standard and quality of the documentation may include compliance with: .policies and procedures .professional, industry and sector standard .relevant legislation .consistency of understanding and documentation practices across organization .identified gaps of inconsistencies and discrepancies .content and context of documentation .requirement of coding -review of the evidentiary compliance of the documentation may include: .document is contemporary .documentation is a factual record(authentic) .documentation is based on evidence and observation(accurate) .timeliness of entries .inclusive of planned care provided and actions taken .documentation is a complete record

5. Clinical competence in relation to Documentation

5.1. Appropriate documentation promotes

5.1.1. a high standard of clinical care and continuity of it, evidence of patient care, an accurate account of treatment, intervention and care planning. * improved: - 1-the communication and dissemination of information between and across service providers. 2- goal setting and evaluation of care outcomes. 3-early detection of problems and changes in health status.

5.2. A clinician’s documentation should be able to demonstrate

5.2.1. * a full account the assessment of the patient and the care planned and provided * relevant information to the patient’s condition at any time and the interventions and actions are taken to achieve identified health outcomes or respond to actual or potential adverse events * evidence that the clinician met their duty of care and taken all reasonable decisions and actions to provide the highest standard of care and that any actions or omissions did not compromise the patient's safety or identified health outcomes * a record of all communications relevant others in relation to the patient

5.3. 5 Ws

5.3.1. WHO? 1-Documentation should be a record of direct knowledge, observation, actions, decisions, and outcomes. Should be recorded by doctors, nurses, midwives, patients, other health professionals, and other care providers. 2-Documentation should reflect:-• use of consistent data collection form • identification of roles and responsibilities of each health care provider • clear process for review, storage and archiving • clarification of: 1-access and communication processes 2-documentation requirements by Medical Record Department

5.3.2. WHAT? • All aspects of patient care . • Collaboration and shared responsibilities between all relevant health professionals/ care providers. • Complete information whether subjective and objective • Observation, assessment, actions, outcomes • Variances from expected outcomes or established protocol • Rationale for decision and actions • Critical incidents involving the patient

5.3.3. WHEN? 1-As a chronological record of actions and events. 2-At the time of or as soon as practicable after: •the action or event • collaborations • variances to expected outcomes • critical incidents • an identified late entry

5.3.4. WHY? • basis of communication between health professionals • informs and is a record of care provided • demonstrates accountability • valuable source of data for research and tool for identifying funding and resource allocation • used to: 1-evaluate professional practice as part of quality improvement 2-abstract details for coding purposes

5.3.5. HOW? • Concise, accurate and true record • Clear, legible, permanent and identifiable • Chronological, current, confidential • Based on observations, evidence, assessment • Consistent with guidelines, organisational policy, legislation • Avoids abbreviations, white space, ambiguity

6. Principles for documentation

6.1. Principle 1: Comprehensive and complete record

6.1.1. Comprehensive and complete documentation and record keeping:

6.1.2. 1) Clear, concise, complete record of clinical care.

6.1.3. 2) Factual, accurate, true and honest record.

6.1.4. 3) No duplication of information.

6.1.5. 4) Legible and non-erasable, permanent, retrievable, confidential, patient-focused and non- judgmental.

6.1.6. 5) Representative and reflective of professional observations and assessment.

6.1.7. 6) Timely and complete.

6.1.8. 7) A complete record including completed forms, charts, methods and systems.

6.1.9. 8) Chronological record of care (late entries recorded as soon as possible as to rectify the absence).

6.1.10. 9) Prefaced with date and time of care or event.

6.1.11. 10) Details of person who provided / documented care.

6.1.12. 11) Source of information.

6.1.13. 12) Inclusive of signatures (or initials) and professional designation of person recording information.

6.1.14. 13) Meaningful and relevant information.

6.1.15. 14) Minimize transcription of data.

6.1.16. 15) Easily interpreted over time and after significant time has elapsed.

6.1.17. 16) Avoid use of abbreviations.

6.1.18. 17) Detailed documentation in relation to critical incidents.

6.2. ‏Guiding Principle 2: Patient centered and Collaborative Documentation is patient centered, patient focused, collaborative and appropriate to the setting in which the care is provided and the purpose for which the information recorded.

6.2.1. Patient centered documentation and record :.

6.2.2. 1-documentation systems and practices appropriate to the specific needs of the patient/patient population and context of the care.

6.2.3. 2-appropriate documentation systems to support shared documentation processes

6.2.4. 3-record of independent and collaborative actions with other health professionals or care providers (eg those ordered by another appropriate health professional)

6.2.5. 4-contemporary, secure, resource efficient documentation systems :

6.2.6. 5-documentation systems relevant to the setting in which the care occurs (including patient held records, electronic records and mobile record systems)

6.2.7. 6-identification of objective and subjective data in documenting assessment of the patient needs/health status

6.2.8. 7-individualized, comprehensive and current plan of care

6.2.9. 8-based on professional observation and assessment that does not have any basis in unfounded conclusions of personal judgments

6.2.10. 9- identifies problems that have arisen and actions taken to rectify/address

6.2.11. 10- frequency of documentation consistent with professional judgement in relation to complexity/stability of patient, organisational policy, standards and legislation

6.2.12. 11- documented valid consent of any clinician proposed intervention or operation

6.2.13. 12- accessible relevant previous/other documentation (including patient history, long and short term intervention, diagnostic investigations most recent previous documentation by other clinical staff.

6.2.14. 13- appropriate supporting documentation systems and forms

6.2.15. 14- documentation of intervention via telephone (including information obtained and advice given)

6.3. Guiding principle 3: Ensure and maintain confidentiality. Clinicians have legislative, professional and ethical obligations to protect patient confidentiality. It is essential that the confidentiality of that information be safeguarded. Electric information, mail and communication systems are increasingly used as effective means of maintaining and transferring documentation.

6.3.1. Confidential documentation and record keeping:

6.3.2. ensure and maintain the confidentiality of the patient.

6.3.3. develop and implement practices that protect confidentiality of information.

6.3.4. records stored and archived confidentiality.

6.3.5. confidentiality of electronic documentation.

6.3.6. systems for sharing information with others ensure only relevant information.

6.3.7. ensuring copies are used, managed and stored appropriately

6.3.8. ensuring copies are readable.

6.3.9. patient records are secure

6.3.10. disposing of documintation

6.3.11. meets requirements for storage and disposal scheduling.