All patient records must not only be organized, but also consistent in their structure. Entries should be made in chronological order to facilitate the search for facts. The patient`s record can only contain information about that particular patient and no one else. Each page of the patient`s medical record must contain the patient`s name or identification number. For other chronic diseases of a cyclical nature, with intermittent symptoms, documented conditions such as “in remission” should always be coded as an active state. Examples include Crohn`s disease, lupus, rheumatoids and other forms of arthritis, multiple sclerosis, etc. Anyone who documents in the medical record should be qualified and/or have the authority and right to document in accordance with the institution`s policies. Individuals must be trained and competent in the institution`s basic documentation practices and legal documentation standards. All authors must be trained and follow their documentation standards and guidelines (i.e., meet documentation deadlines).
In addition, the patient must know who to call in an emergency. Many readers will find these elements to be very similar to a competency assessment; That is what is at stake. If the doctor asks the patient the above implicit questions and records the patient`s answers, monitoring of changes in the patient`s condition may be delegated to that patient. Using labels offers a number of advantages: 1) They are often computer generated and are usually typed to provide a readable record/document such as progress notes. 2) When used in the process of transcribing doctors` prescriptions into a clinical computer system, they can help reduce or eliminate transmission errors by printing the order in a consistent format for all areas of the record (telephone prescription, medication/treatment record, doctor`s order sheets). and 3) If demographic labels are used in the file, it is more likely that complete information will be provided on each page of the file to identify the resident, rather than relying on staff to enter the demographic information. The Council recognises and promotes the trend towards the use of electronic patient records (ÖRH). The promise and potential of information technology in health care, particularly the use of EHRs, poses particular challenges for licensees.
While the Council encourages the adoption and appropriate use of various forms of EHEA, there are unique aspects and issues related to EHEA that the Council has encountered on several occasions, some of which are discussed below. The purpose of this paragraph is to identify issues that the Commission has repeatedly found problematic in cases of misconduct and complaints of which the Commission is informed. The well-established basic principles of medical record documentation, as described above, apply to all forms of medical record documentation, including EHRs. Licensees should not transfer control of their patients` medical records to third parties unless there is a binding agreement containing adequate provisions to protect patient confidentiality and ensure access to these medical records.* It is important to identify the clinicians involved in the medical records. When registering employee names, specify an employee`s name and discipline. For example, “The patient was treated by R. Smithers, RN.” This complements the clear and concise format required to provide the relevant information in a particular case. All entries in the medical record must be legible.
Illegible documents can endanger the resident. Readable documentation helps other caregivers and helps ensure the continuation of the resident`s care plan. If the entry cannot be read, the author must rewrite the entry on the next available line, define what the entry is to reference the original documentation, and rewrite the entry legibly. Example: “Clarified entry of (date)” and rewriting of the entry, date, and sign. The newly written entry must match the original.