Assignment task:
Respond to the discussion in a friendly manner; along with add in citation and APA standards reference:
Within the Condition of Participation in hospitals, I chose the standard: Content of Record. To begin with the medical record is required to contain justifiable diagnosis information for admission and if applicable continued hospitalization. All record entries must be legible, with date/time stamped, and authenticated by the Individual providing services. Electronic and verbal orders also must be date/time stamped and authenticated by the prescriber. Records must have a patient's medical history and physical exam; completed and documented no more than 30 days before or 24 hours after admission and registration. The records must contain the admitting diagnosis, results of all consultative evaluations; Any complication, HACs, negative reactions to medication or anesthesia must be included. Consent forms must be up to date and present. All patient information from anyone treating that patient must be up to date for proper monitoring of their condition. The discharge summary must be completed within 30 days of discharge.
If a diagnosis is not accurate or complete in the details needed for admission to the hospital this can result in errors in treatment of the patient, legal liability and/or financial penalties for the medical facility.
All record entries and orders, whether they are electronic or verbal must have the matching date and time stamped, legibly written, and authenticated by the individual providing services or dictating the orders. Without accurate documentation on entries and orders there can be coding inaccuracies, claims can be denied or reimbursements delayed, Patients may not receive correct treatment that physicians have ordered causing lack of care and possibly be more detrimental for patients' health.
Having an up-to-date accurate physical exam is crucial for treating patients. It lists the medical history allergies and current medications which if they are not documented could lead to negative outcomes for patients' health. A patient may have a reaction to a medication given during the hospital stay that they're not supposed to have because of a medication they're already on. If a patient is allergic to something like anesthesia that is not documented that could create a very harmful reaction to include a possible fatality. One instance I know of, from a friend she is severely allergic to shellfish, if she encounters anything with iodine, she can have an anaphylactic reaction which without her EPI pen can be extremely severe. Therefore, an updated and reviewed medical history and physical exam is tremendously important.
Consent forms must not only be up to date and present, but they should also be standardized so other facilities can access information easily. Making the information consistent helps reduce missing information in a patient's medical records and assists in expediting a patient's care more efficiently. Physicians and other medical providers will not be spending time searching for needed information having to check if documentation has been completed previously.
Any missing or out-of-date information may delay patient care acquiring medical staff to waste time searching for information That should have been documented at the time it occurred.
Any delay in the discharge summary beyond 30 days may lead to lost or incomplete information. This has the potential to result in delays in claims processing, rejections of claims, legal consequences, and damage to the facilities' reputation. Need Assignment Help?