Medical Record Documentation Essay
Medical Record Documentation Essay
Discuss your State Board of Nursing nurse practitioner documentation guidelines and how this can impact your level of reimbursement in the clinical setting.
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Precise, accessible and accurate documentation is a basic element of high quality evidence-based nursing practice. Generally, in Colorado, medical record documentation is essential for recording the facts about a patient, relevant findings and observations on the health history of an individual (Bluestein, 2014). This should also include the illnesses that a patient has suffered from in the past and present, the tests done, treatments and final outcomes. This documentation serves to communicate with other healthcare providers within healthcare teams and to provide information for other organizations (Bluestein, 2014). In this context, other organizations primarily refer to institutions or individuals involved in credentialing, accreditation, regulation, legislation, research, reimbursement and other quality activities (Saifee & Bardhan, 2017).
The Colorado State Board of nursing also requires that advanced nurse practitioners who do medical documentation should be authorized and be licensed by Colorado State Board of Nursing to practice as nurse practitioners. Nurse practitioners should avoid using abbreviations, jargon and language that cannot be easily recognized by other healthcare practitioners (Rantz, et al., 2017). Recorded information should demonstrate one’s ability in written and electronic communication, be specific to a client and should include all the nursing care provided in a patient’s record.
Since APNs are credentialed providers, they are required by the state to fill all elements of a patient’s visit including the characteristics of a patient and outcomes of care. This information ought to be filled according to the documentations guidelines by the Centers for Medicare and Medicaid services to support bills, so that the correct reimbursements are made (Clynch & Kellett, 2015). In Colorado, nurse practitioners can efficiently execute all these roles without the supervision of s physician since they also have a full practice authority.Medical Record Documentation Essay
Reference
Bluestein M. P., (2014). Standards In Colorado Medical Records Documentation.
Clynch, N., & Kellett, J. (2015). Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. International journal of medical informatics, 84(4), 221-228.
Rantz, M. J., Birtley, N. M., Flesner, M., Crecelius, C., & Murray, C. (2017). Call to action: APRNs in US nursing homes to improve care and reduce costs. Nursing outlook, 65(6), 689-696.
Saifee, D. H., & Bardhan, I. R. (2017). Healthcare outcomes, information technology, and Medicare reimbursements: a hospital-level analyses. International Journal of Electronic Healthcare, 9(2-3), 129-156.
Medical record documentation is required to record pertinent facts, findings, and
observations about an individual’s health history, including past and present illnesses,
tests, treatments, and outcomes. The medical record chronologically documents the
care of the patient and is an important element contributing to high-quality safe
care.
Requirement 1 page (250+- words)
The minimum number of page(s) (1) doesn’t include cover and reference pages.
Content must be substantive, qualitative and answer the discussion board questions.
Do not add sentences/paragraph which has no relevancy to your discussion board
questions as listed above. Do not re-ask the questions and reference list doesn’t count
for word count.
Must meet following rubrics:
You must answer all rubrics adequately, in absence of that you will not get the required
grade and you will be required to withdraw from this course. This applies to any of the
assignments/discussion board questions.
Requirement 1 page (250+- words)
The minimum number of page(s) (1) doesn’t include cover and reference pages.
Content must be substantive, qualitative and answer the discussion board questions.Medical Record Documentation Essay
Do not add sentences/paragraph which has no relevancy to your discussion board
questions as listed above. Do not re-ask the questions and reference list doesn’t count
for word count.
Must meet following rubrics:
You must answer all rubrics adequately, in absence of that you will not get the required
grade and you will be required to withdraw from this course. This applies to any of the
assignments/discussion board questions.
All assignments will be submitted to Turnitin.
This is graduate school. I expect graduate-level work and professionalism, as we are all
professional nurses. The minimalist approach will not be tolerated and I will not accept
a sub-par assignment. You will receive a zero without an option to resubmit.
Do not add sentences/paragraph which has no relevancy to your case studies – be
specific – need to be qualitative – these papers are very specific so you need to
explain specific guidelines
(Does not re-ask the questions and reference list doesn’t count for page/word count
Do not do OVER-QUOTING)Medical Record Documentation Essay
DOT (.)com sites are not accepted in this course.
Up-to-date, e-Medicine, Medscape, ePocrates, Web-MD, hospital-based publications
(Mayo, John’s Hopkins, etc.), the encyclopedia and the dictionary are not to be used
as references. I add to this section every term as someone always surprises me with
something!
As NPs, we must support use of evidence -based approaches to medicine. Websites
such as:
1. http://www.cochrane.org/,
2. www.ebscohost.com/dynamed/
3. http://guideline.gov/
These are supported by evidence-based data.
References are to be from primary sources, peer-reviewed, and evidence-based. Do
not use references >4 years old (strongly prefer <3 years), unless landmark study.
APA 6th edition is the expectation and I do check references. Do not plagiarize. I also
use a web-based plagiarism tool if I suspect work that is not original. If I have a high
suspicion, I will use Turn It In account, which is then part of the national plagiarism
database of thousands of documents. For this course, I expect a similarity level of 0%-
10% or less.
You may be asked to submit your research journal/documents which you have used for
reference.
A graduate student should be able to write cohesive sentences using Standard
English. Grammar, punctuation and APA rules should be followed. No dangling
participles or split infinitives, ladies and gentlemen! Sloppy work will not be tolerated
and will be returned with a grade of 0.Medical Record Documentation Essay
Be sure to spell-check and proofread your work before turning in the final product. Just
because the rubric doesn’t require me to assess a score, I will use my professional
judgment.
Types of Medical records
There are several types of medical records and how they are used. Accessing the electronic health records now in the medical field because any digital record online provides access in a virtual form, it makes it easier for the doctors to review a patients record and test results almost immediately. Electronic records also allows you to view patient’s information and notes on file from other doctors without having to relocate a paper chart. When paper charts were put away and pulled some of the documents were hard to read especially doctors who had illegible handwriting. Now with electronic records any information put into the electronic database and saved is legible for whoever is reviewing the file. “Paper records” on the other hand that are stored have to be kept on hand for at least 6 years due to healthcare regulations just in case treatments are needed. Plus someone with a big medical history needs a substantial amount of space because of the paper trail. Electronic medical records are the digital version of the paper charts in doctors’ offices. With EMR’s they have advantage over paper records such as;
It’s easier to identify patients who are due for certain screenings and checkups
Also it allows you to track data overtime Medical Record Documentation Essay
Types of Medical records
There are several types of medical records and how they are used. Accessing the electronic health records now in the medical field because any digital record online provides access in a virtual form, it makes it easier for the doctors to review a patients record and test results almost immediately. Electronic records also allows you to view patient’s information and notes on file from other doctors without having to relocate a paper chart. When paper charts were put away and pulled some of the documents were hard to read especially doctors who had illegible handwriting. Now with electronic records any information put into the electronic database and saved is legible for whoever is reviewing the file. “Paper records” on the other hand that are stored have to be kept on hand for at least 6 years due to healthcare regulations just in case treatments are needed. Plus someone with a big medical history needs a substantial amount of space because of the paper trail. Electronic medical records are the digital version of the paper charts in doctors’ offices. With EMR’s they have advantage over paper records such as;
It’s easier to identify patients who are due for certain screenings and checkups
Also it allows you to track data overtime Medical Record Documentation Essay
Healthcare can be known for a complex industry. Every day is a new day facing complicated clinical administrative transactions with electronic medical records and safety? Health Information technology is suppose to realize errors using electronic medical records. Leaders must understand the complexity and safety issues in order to help mandate electronic medical records with design, development, implement and use. In the last decade, this article has informed executives, clinicians, and technology. Their main focus was on these three areas computerized physicians order entry. Their main focus was to work all three areas computer physician order entry, computer decision support system, …show more content…
Health care is the most complex system with complicated transactions that could result in behavioral changes. One way is patients and clinicians should demonstrate how challenging it is to help maintain patient information. Clinical information systems by difficulties in demonstrating they are also challenged in maintain patient health information. Another land mark article described anecdotal evidence that while electronic medical records and associated clinical information systems can reduce errors, they can also cause errors. (Bates et al. 2001) Computerized physician order entry has reduced errors in patient care by trying to eliminating illegible orders and transcriptions errors. Researchers also found that computerized physician order entry can increase the coordination load among clinician resulting in new opportunities for new sources of error. (Cheng et al.2003) A nurse may be unaware of new patient order by soling imputing the information into the computerized physicians order.Medical Record Documentation Essay
