Documentation Requirements for the Acute Care Inpatient Record Essay Example for Free

Documentation Requirements for the Acute Care Inpatient Record EssayThe checkup lay is a tool for collecting, storing, and processing patient information. Records are being used daily for a multitude of purposes, including providing a means of communication between the mendelevium and the other members of the healthcare team caring for the patient providing a basis for evaluating the adequacy and appropriateness of care providing data to substantiate insurance claims protecting the juristic interests of the patient, the facility, and the physician providing clinical data for research and education ?General Guidelines for Patient Record Documentation ? Each hospital should have policies that ensure uniformity of two content and format of the patient move into based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards. ? The patient get in should be organized systematically to facilitate data retri eval and compilation. ? Only persons authorized by the hospitals policies to inscription in the patient record should do so.This information should be recorded in the medical round rules and regulations and/or the hospitals administrative policies. ? Hospital policy and/or medical staff rules and regulations should specify who may receive and transcribe a physicians verbal orders. ? Patient record entries should be documented at the cartridge clip the treatment they describe is rendered. ? Authors of all entries should be clearly identifiable. ? Abbreviations and symbols in the patient record are permitted only when approved according to hospital and medical staff bylaws, rules, and regulations.All entries in the patient records should be permanent. Errors should be corrected as follows draw a single line in ink through the ill-judged entry, and print error at the top of the entry with a legal signature or initials, date, time, title, reason for change, and discipline of the pe rson making the correction. Errors must never be obliterated. The existing entry should be left intact with corrections entered in chronological order. Late entries should be labeled as such. ? In the final result the patient wishes to amend information in the record, it shall be done as an addendum, without change to the original entry, and shall be clearly identified as an additional document appended to he original patient record at the direction of the patient, who will thereafter bear responsibility for the explaining the change.The health information department should develop, implement, and evaluate policies and procedures link up to quantitative and qualitative analysis of patient records. ? Review any requirements outlined in state law, regulation, or healthcare facility licensure standards as they relate to musical accompaniment requirements. If your state requires that verbal orders be authenticated within a specified time frame, accrediting and licensing agencies will survey for compliance with that requirement.