Running header: REFLECTION 3 5

Reflection 3

Aaron Bryant

Shorter University

BUS 6720 Healthcare Informatics

November 25, 2019

Reflection 3

Patient Record Documentation Guidelines

General Documentation Issues

The best way to prevent a documentation issues is by recognizing the most frequent documentation errors and putting procedures in place to stop them. HIM experts state that the top four documentation mistakes are mixed messages from a physician, such as dictation or illegible handwriting, the misuse of copy and paste or copy forward functions in the EHR, incomplete or missing documentation, and misplaced documentation. To reduce these mistakes clinical documentation improvement (CDI) programs have been created. The growth of CDI has been driven by the increased specificity needed for ICD-10-CM/PCS, as well as the transition to pay-for-performance versus fee-for-service payment methodologies (Butler, 2015).

Hospital Impatient Record- Admin Data

Administrative data in the impatient record consist of demographic, socioeconomic, and financial information. This information is gathered at admission or prior to admission on the phone on the following sheets:

Face Sheets – contain patient identification or demographic, financial data, and clinical information.

Advance Directives – legal document in which patients provide instructions to how they want to be treated if they become ill to the point of no reasonable recovery. The instructions direct health care providers to the preferences of the patient’s care.

Informed Consent – Consent documents that that give physicians the release to treat patients

Patient Property Form – record of items patient brings to the hospital.

Birth Certificate (copy)

Death Certificate (copy)

Hospital Impatient Record- Clinical Data

The clinical data in the impatient record contains all health care information obtained from about a patient’s care. In the inpatient setting, some of the important pieces of inpatient documentation include:

Attending Physician Documentation

The attending physician is the central point for all documentation in the patient's record. It is the responsibility of the attending physician to determine the relevance and importance of all other documentation in the patient's record.

The patient's history and physical is one of the first pieces of documentation that appears on the patient's record. This document usually includes not only information pertaining to the patient's history, but more importantly, pertinent information regarding the patient's current condition. Here, the attending physician should document his/her assessment of the patient's current condition. It is possible that the attending may be working with symptoms and differential diagnoses at the time of the history and physical exam.

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