The main reason for maintaining medical records is to ensure continuity of care for the patient . ... For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.
Why is it important to document medication use and treatments?
The process of medication reconciliation can significantly decrease errors. It involves obtaining, verifying and documenting a list of the patient’s current medicines and comparing this list to the medication orders and the patient’s condition to identify and resolve any discrepancies.
Why is it important to document medication administration?
Prescription orders and medication administration documented in patient records allow nurses and physicians, working across time and locations, to access relevant information at any point in time .
Why documentation of medication is important?
Clear and concise medical record documentation is critical to providing patients with quality care , ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care.
What is the important of record keeping?
You need good records to monitor the progress of your business . Records can show whether your business is improving, which items are selling, or what changes you need to make. Good records can increase the likelihood of business success.
Why do we manage drugs?
When patients are not experiencing desirable outcomes from their treatment regimen, Medication Management allows experienced healthcare providers to evaluate not only the list of medications the patient is taking, but also their use of vitamins and other supplements to understand how these different drugs interact to ...
What is medication reconciliation and why is it important?
Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking . This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
Who is responsible for medication reconciliation?
Patients and families are involved in medication reconciliation. Guiding Principle 7: Staff responsible for reconciling medicines are trained to take a BPMH and reconcile medicines. The context (or environment) in which the Medication reconciliation SOP is implemented will influence the success of its implementation.
What are the steps in medication reconciliation?
Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).
What is the purpose of documentation?
The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams , and other hard- or soft-copy written and graphic materials.
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.
What are five major purposes of medical documentation?
- Patient Care. Patient records provide the documented basis for planning patient care and treatment.
- Communication. ...
- Legal documentation. ...
- Billing and reimbursement. ...
- Research and quality management.
What are the characteristics of record keeping?
- routinely capture records within the scope of the business activity it supports.
- routinely create process metadata.
- provide adequate information about the records within them.
- have controls that will ensure accuracy and quality of records created, captured and managed.
Why it is very important to keep business records?
Record-keeping is so vital for businesses in all industries and of all sizes because it keeps you on track with your financial commitments, both internal and external .
Why is it important to record information accurately?
Clear, accurate records support clinical decision-making and patient care. Document each patient interaction as soon as possible. It’s important to maintain the integrity of the record . Records can be used as evidence in the event of a complaint or claim.
What is the goal of medication reconciliation?
Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications ...
