Medical documentation is an integral part of practice to ensure safe and effective care. Documentation is a record of the care provided by a health care provider; and is a primary communication between health professionals. Comprehensive and complete record - clinical staff have a professional obligation to maintain documentation clear‚ concise and comprehensive as an accurate and true record of care. Patient centred and collaborative - documentation should be centred to the specific needs of the
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Hybrid Records and Retention Rules Jessica Fisher WGU Missouri Hybrid Records and Retention Rules Hybrid records are records that are part paper based and part electronic health record. They are a common occurrence due to the implementation of the electronic health record. Many facilities have not gone to the complete form of the electronic record and must keep partial portions of the medical record in paper form. The hybrid record is a step up from the all-paper record in many ways. It allows
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- Law and Management in Occupational Health and Safety Patients in the Perioperative environment are often required to be repositioned on the operating table and most of these patients have had a regional or general anaesthetic‚ making it impossible for them (the patient) to assist staff in that repositioning. The added risk in any repositioning is loss or damage to the patients’ airway‚ and maintaining the patients’ musculoskeletal alignment‚ so as to not cause any damage to nerves
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Medical Malpractice | The Good‚ the Bad‚ the Ugly | | | | | The outcomes of medical malpractice lie in the following explanation of perspectives‚ referred to as “the good‚ the bad‚ and the ugly.” This paper provides a presentation of facts of the two highest single-incident medical malpractice lawsuits in Connecticut: Daniel Jacob D’Attilo et al. v. Richard Viscarello et al. (Case 1) and Elizabeth Oram and Simon Oram as Parents and Next Friends of Spencer Oram at al. v. Corinne
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Nursing management for a patient with chronic obstructive pulmonary disease begins with assessment; gathering information from the patient including detailed medical history‚ present symptoms and evaluate findings of diagnostic tests. Symptoms vary with each patient‚ but may include chronic cough‚ clubbing of the fingers‚ chest tightness‚ weight loss‚ cyanosis‚ difficulty breathing with a higher rate of respirations and difficulty sleeping (Weber‚ 2008). It is common for patients suffering from difficulty
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Confidentiality and making patients feel confident in giving us their information. Confidentiality is taken advantage of every day by healthcare professionals. HIPAA states that healthcare professionals should not give information such as date of birth‚ patient name‚ or social security number. What about talking to your significant other or best friend about a patient you examined today with an ominous skin malady? You apprehend it every day in the healthcare field. Nurses talking to one another
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Social Implications of the Internet: On equality‚ human relations‚ and effort The internet or the cyberspace has rapidly grown since the start of the 21st century. I would reckon that there are more and more people in developing countries who have access to the internet and that the great divide is slowly decreasing. The world of technology and the age of information could be the main cause of its rapidity. Everyday the internet offers millions of new information‚ new products‚ and new methods of
Free Sociology Interpersonal relationship
Vandalism‚ such as tagging or damage of property‚ has been becoming a serious problem in society. It has come to the point where vandalism seems like an everyday activity which has been creating problems for our government. Since vandalism is becoming a serious problem in our society‚ punishments like fine should be replaced with community service. Despite people thinking that fines have a strong effect‚ these consequences are not really working. If fines were effect‚ vandalism would not be a
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Patient scenario The patient Mr. Smith was diagnosed with prostate cancer 5 years ago. It seemed as if his condition was worsening so he visited his physician who performed a physical examination on him. A physical examination has many components they include observing the signs of a disease by checking for signals like change in skin pigment or alertness. Then there is checking vital signs such as blood pressure‚ heart rate and temperature by comparing your results to a standard. Next step the
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institute that are referred to as records. This information generated is also use for projecting and planning purposes. (Managing records at school level). Managing and organization student’s records into a cohesive and efficient might seem like an impossible task‚ but it depends how much effort is placed in it‚ that makes it possible. School that properly manages their records meets its legislation responsibilities‚ aids its administrative processes and ensures that records are stored when needed and destroyed
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