Quick Answer: What Is Care Documentation?

What are the different types of medical documents?

Here are the documents all health care providers should have translated.Patient Information Form.

Patient Rights & Responsibilities.

Consent and Assent Forms.

Patient Instructions.

History Questionnaires and Progress Notes.

Missed Appointment Policy.

Patient Financial Responsibility Waiver..

What is the meaning of documentation in nursing?

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems: Effects on nursing practice and healthcare outcomes.

Which of the following is an example of point of care documentation?

What is an example of point-of-care documentation? Disease prevention, diagnosis and management and the detection of adverse events are all examples of which one of the core functions that an EHR should be able to perform according to the IOM report? What is a characteristic of an EHR system used by a medical office?

What is a POC lab test?

Point-of-care (POC) testing involves performing a diagnostic test outside of a laboratory that produces a rapid and reliable result, aiding in identifying or managing chronic diseases and acute infections.

What is another name for point of care testing?

POCT can be defined as “diagnostic testing conducted close to the site where clinical care is delivered”. Other names for POCT include: near-patient, decentralized, ancillary, alternate site, patient-focused, bedside, satellite, and peripheral testing.

What are Documentation Standards?

The best way to get documentation that works is to establish documentation standards. These are the rules that guide the creation and distribution of documents within your team or organization.

What is an example of point of care testing?

The most common point-of-care tests are blood glucose monitoring and home pregnancy tests. Other common tests are for hemoglobin, fecal occult blood, rapid strep, as well as prothrombin time/international normalized ratio (PT/INR) for people on the anticoagulant warfarin.

What is the meaning of documentation?

Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. … Documentation is often distributed via websites, software products, and other online applications.

What are the three C’s of accurate documentation?

Most care providers believe that their documentation is clear, concise comprehensive and timely.

Who can document in a medical record?

Anyone documenting in the medical record should be credentialed and/or have the authority and right to document as defined by facility policy. Individuals must be trained and competent in the fundamental documentation practices of the facility and legal documentation standards.

What is the point of care documentation?

Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients.

What are the basic rules of documentation?

In my eyes, there are eight rules that we can follow to produce good documentation:Write documentation that is inviting and clear.Write documentation that is comprehensive, detailing all aspects of the project.Write documentation that is skimmable.Write documentation that offers examples of how to use the software.More items…•

What does POC mean in healthcare?

Point-of-care testingNational Institutes of Health definition of POC. “Point-of-care testing allows patient diagnoses in the physician’s office, an ambulance, the home, the field, or in the hospital. The results of care are timely, and allow rapid treatment to the patient…”

What is glucose point of care testing?

Point-of-care testing (POCT) for glucose at the bedside or in the home or hospital is used to monitor patients with diabetes—not to establish the diagnosis of diabetes mellitus.

Important Legal DocumentsPhysician Orders for Life-Sustaining Treatment (POLST)Durable Power of Attorney (DPOA)Health Insurance Portability and Accountability Act (HIPAA)

Why is documentation so important?

Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations. In this same manor, it is important to record information that can help support the proper treatment plan and the reasoning for such services.

Are EHR and EMR the same thing?

There can be some confusion about the distinction between an EHR (electronic health records) system and an EMR (electronic medical records) system; in fact, EHRs and EMRs refer to the same thing and have often been used interchangeably. … And EHRs go a lot further than EMRs.”

Who performs point of care testing?

In 52% of the institutions, POCT is performed by nursing staff members. Only 8% of the survey respondents indicated that medical technologists perform POCT. Medical laboratory technicians perform less than 1% of POCT.