Which of the following information would be documented under the plan of action?

Índice Show

Action 6.11 states
Reflective questions
Strategies for improvement
Which of the following applies to HIPAA requirements quizlet?
In which year did enforcement of the HIPAA Act dealing with patients rights begin with penalties?
Which of the following are guidelines to consider when using a progress note?
Which element of the documentation includes the provider's objective findings?

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Documentation is an essential component of effective communication. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis and harm.1,2

The intent of this criterion is to ensure that relevant, accurate, complete and up-to-date information about a patient’s care is documented, and clinicians have access to the right information to make safe clinical decisions and to deliver safe, high-quality care.

Documentation can be paper-based, electronic or a mix of both. It can also take a number of forms, including the care plan, handover notes, checklists, pathology results, operation reports and discharge summaries. For this criterion, organisations are required to have in place systems to ensure that essential information about a person’s care is documented in the healthcare record. For documentation to support the delivery of safe, high-quality care, it should:3

Be clear, legible, concise, contemporaneous, progressive and accurate
Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes
Meet all necessary medico-legal requirements for documentation.

Regardless of who records information in the healthcare record, organisations need to ensure that their systems and processes for documentation meet the requirements of this standard. This involves supporting the workforce to document information correctly, and could include policies or training that clearly describe:

The workforce’s roles, responsibilities and expectations regarding documentation
When documentation is required
How to gain access to the healthcare record and templates, checklists or other tools and resources that support best-practice documentation.

Clinical information systems and technologies play an increasingly important role in documentation in the healthcare system. It is essential to consider the safety and quality issues that may arise when designing, implementing or integrating digital health solutions. Any digital health record system that is implemented should meet the elements of best-practice documentation and support effective clinical communication.

This criterion is supported by actions in the Clinical Governance Standard that require organisations to make the healthcare record available to clinicians at the point of care, support the workforce to maintain accurate and complete healthcare records, and integrate multiple information systems if they are used (Action 1.16).

Item

Action 6.11 states

The health service organisation has processes to contemporaneously document information in the healthcare record, including:

Critical information, alerts and risks
Reassessment processes and outcomes
Changes to the care plan

Intent

Relevant, accurate, complete and timely information about a patient’s care is documented in the healthcare record to support safe patient care.

Reflective questions

How does the health service organisation describe the roles, responsibilities and expectations of the workforce regarding documenting information?

What processes are in place to ensure that complete, accurate and up-to-date information is recorded in the healthcare record and is accessible to clinicians?

Key tasks

Develop and implement systems to support the contemporaneous documentation of critical information in the healthcare record.
Record the organisation’s documentation policies and make them available to the workforce.
Communicate to the workforce their roles and responsibilities for documentation.

Strategies for improvement

Which of the following applies to HIPAA requirements quizlet?

Which of the following applies to HIPAA requirements? Healthcare facilities must inform patients, in writing, about disclosure of identifiable health information.

In which year did enforcement of the HIPAA Act dealing with patients rights begin with penalties?

Enforcement of the Privacy Rule began April 14, 2003 for most HIPAA covered entities. Since 2003, OCR's enforcement activities have obtained significant results that have improved the privacy practices of covered entities.

Which of the following are guidelines to consider when using a progress note?

The following are some important guidelines to consider when using a progress note: It must be arranged in reverse chronological order. Every entry must be initialed and signed by the person making the entry. Typically, the first initial, last name, and credentials are used.