Some days you get out of bed, stretch your arms, open the windows, and welcome the sunshine feeling so good and ready to face the world outside. Other days you wake up wanting to do the same thing but when you open the windows, no warmth comes in, the sun is up but you’re feeling kind of cold, unwell and so you decide to go back to bed and hide under the comfort of your covers. You may also see medical note templates.
A few hours later, it’s more than just simply not feeling well because you have the flu and a day or two later, it still didn’t go away. So when you decide to pay the doctor a visit, which is really the best decision yet, even though some people may argue that these days, a checkup for fever or a slight cold is not really required, unless it escalates. But you’re already on the “escalate” part so here you are, talking to the nurse, waiting for the doctor and hoping you’ll be okay soon because you have a stack of paperwork waiting at work. You may also see progress note templates.
Usually, people would just continue with their daily lives, get to work and go through the day. If they feel any physical pain and feel like they need some sort of pain relief, they just go to the drugstore and buy over-the-counter medicine or pills when they don’t keep a supply at home, although most people easily have first aid kits in their cabinets. But first aid can only do so much. You may also see sample medical notes.
For one, it should never be an alternative to the cure you get from the clinic or the hospital when what you are feeling is already causing your body some serious signs of trouble. It also doesn’t give you an accurate account of how you’re doing with the medicines you are taking or whether or not you are getting better at all. Progress for an illness or a medical condition, especially those that require immediate attention and proper care that can only be provided in the hospital or clinic, is very important to check and document. You may also see doctor note samples.
Records Or It Didn’t Happen
“If there’s no record/documentation, then it didn’t happen,” so goes a hushed courtroom anecdote, which is really hard to argue. How many times have we heard these words from the plaintiff’s counsel when we see a case being tried? It’s actually no more than an anecdote than an old saying but one things remains to be true. There is so much that’s happening that doesn’t get documented and that’s not good, especially in the medical profession, on so many levels. Documentation and record-keeping of medical progress needs to always be complete, accurate, concise and done in a timely manner. You may also see death note templates.
It’s an issue that gets easily brushed off when the patient is already handed down the results for certain lab tests done, recommendations and prescription for medication, as well as advise to visit again so that they can check for progress of their condition, just to be sure. Having a record of a patient’s condition and progress throughout the period of his medication and hospital stay for patients admitted, should always be a doctor and a nurse’s priority. The work requires it, and the medical profession in general demands it, for the sake of maintaining ethical standards at the very least. You may also see nursing note templates.
Risk management does not necessarily demand to have medical and health professionals writing more, but rather to document the facts and findings regarding patient they vowed to serve and take care of, so that the record in way, is like a book. It is not to be mistaken with the patient’s daily chart because that’s for continued care. Having a well-documented record facilitates care, leaving little to no worries of a liability if a claim should ever occur. Defensive documentation shouldn’t drive how a chart is developed and maintained.
Good documentation records the basic facts of patient care and what it had involved, including but not limited to who made the notes as well as the results and findings. Compilation of important clinical details and putting them in one place allows a practitioner to remember crucial events that happened later when they perform a treatment. An accurate record of a patient’s complaints and the symptoms are also very helpful when the patient is already under another nurse’s or doctor’s care, allowing them to determine patterns and trends at the same time guiding them in developing further treatment. You may also see doctor note templates.
The medical profession isn’t limited to the offer and availability of services and a practitioner’s experience and expertise. Competent health professionals include good note-taking and documentation as one of the key parts of their jobs because this is where their knowledge in clinical language comes in handy. Furthermore, using clinical knowledge helps ensure the accuracy of patients’ information. You may also see simple note templates.
Symptoms, any complaints of pain, other signs of a looming illness, progress from previous medication or lack thereof, how the patient’s body reacts to the treatment, all these should be appropriately recorded, real-time by taking down notes to make sure that all aspects of the treatment, such as her or his present condition, need for further medication, recommendations for any further treatment, development in the treatment process, and mental, emotional, and physical state are monitored properly. You may also see sample note templates.
In any healthcare profession and even in law, there is a common for practitioners, and that is documentation. If you have diagnosed someone and talked about the diagnosis, there is no credibility in it if no record exists. It’s pretty simple. Failure to keep a patient’s medical progress properly recorded can especially be detrimental when worse comes to worse and you find yourself facing a lawsuit. You can’t also trust your memory in knowing how a patient is doing when it comes to progress with the treatment unless you have noted everything you have done. You may also see case note templates.
Based on an a November 2006 report by the Ontario Ministry of Health and Long-term Care, proper record keeping helps a patient’s improvement long after he or she has left the hospital. There is approximately 20 percent of patients who have negative experiences after they have been discharge, with a few of them being reactions to prescription drugs, side effects and infections and in some cases, complications from clinical procedures, most of which are the result of misinformation or delayed records that subsequent health care providers receive. You may also see nursing note templates.
The same report also indicated a 2003 research that found patients with a gross lack of health records which had them spending another hour and a half in emergency rooms. These situations could have been avoided, lest they result in what would then be considered as medical malpractice, which wouldn’t look good in any medical establishment’s record. You may also see therapy note templates.
There’s a good part of expenses you have incurred during treatment that your healthcare insurance covers and the processing of claims and reimbursements for this wouldn’t be otherwise done in a timely and organized fashion if not through proper documentation of the clinic you have received treatment from. As a matter of fact, experts assure that the accuracy of reimbursement is dependent on competent record-keeping. As for the rest, you have to leave it to your knowledge of certain rules set down by the state and the federal government. You may also see sample nursing report templates.
Sound record keeping is so underrated that people in the health profession don’t realize the massive role it plays in quality assurance. It takes more than an ability to write accurate initial findings and progress notes because it also takes commitment and this helps improve patient care standards as it requires doctors to think their steps carefully and perform according to, or more than what their job demands. You may also see death note templates.
Over time, professionals are able to make room for self-reflection which is important for professional development, commitment to ethical standards and maintaining competitiveness in the profession by providing excellent clinical care to their patients. Documentation also allows members of the team to grow as they learn from each other and work as one on how they can coordinate their skills for better patient care. You may also see free note templates.
Medical Documentation Basics
As a member of the medical profession, it is your responsibility to make sure the following points are followed for proper note-keeping.
You should be able to explain what treatment would be performed and what medication is to follow after the patient is discharged and findings lead the patient to the type of treatment and medication you are giving. You may also see counseling note templates.
Do not ever let your personal biases affect your judgment of a patient’s condition for you don’t personally know who he or she is. Keep it professional and maintain patient-doctor confidentiality. That is what respect mostly means in the healthcare profession. Treat the patient like his life depends on you because in a way, it really does. You may also see best note templates.
Your records should correspond with the treatment process you have performed and laboratory tests that the patient had been required to get in the hospital. Failure to write about your assessment and the progress of the patient, and the lack of explanation for the type of treatment you performed and medicines you have prescribed as well as recommendations, wouldn’t help your case when a patient decides to take you to trial. It would be the person’s word against yours, and you can bet your word wouldn’t hold much weight without any documentation to back it up. Records or it didn’t happen, remember? You may also see note templates in PDF.
Patient notes or any form or part of medical records for that matter are an integral tool in treating patients and giving them the care they deserve because patient care goes beyond being able to cure them of their illness. Medical records, however, have been too often overlooked regarding their importance and the way they should be maintained. In many cases, employees who already have a lot on their hands and not enough time to ensure proper detailing of every patient record, are the ones doing the documentation. But the others, like doctors and people in the emergency area, also need to go the extra mile at times and handle this important task.