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The Importance of Accurate Clinical Documentation Case Solution & Answer

The Importance of Accurate Clinical Documentation Case Solution

Project Description

The process of record keeping in clinical terms is considered to be a fundamental component in the improved professional practice and provision of quality services in the healthcare management. (Alexander Mathioudakis, 2016) In this study, the importance of accurate clinical documentation is to be evaluated, which primarily  focuses on the health information management based on its practices as well as the  principles, and its influence on the data management of patients. The primarily purpose of this research is the identification of critical issues regarding the clinical documentation, impact of health information management and their systems, and determination of some potential strategic approaches for an effective management of health care information.

The study includes a preliminary systematic review in relevance with the literature review on the importance of clinical documentation with major focus on its significant advantages and challenges related to the health information. Additionally, the role of Health Information Management professionals in the delivery systems of healthcare highlights the informatics and information technology in terms of health. (Taiwo, Relevance of health information management (HIM) and the roles of HIM professionals in healthcare delivery systems., 2014 )

Statement of Problem:

As the main purpose of the clinical documentation is same as describing the medical history of a patient while assessing him. Oral or written documentation often misses some information data that needs to considered, which badly affects the treatment process of the patient. Therefore, it is required either by a physician or a nurse to appropriately understand the past medical history of the patient, particularly regarding medical care the patient received. Considering the perception of Health Information Management professional, they tend to contempt to the processes of clinical coding,as they lack understanding respective responsibilities to medical confidentiality. The prevalence of only few HIM professionals are known to work in settings where the health information systems are operated with the existence of skill gap of information technology providing incompatibility with their respective roles in the systems of health information.

Project Objectives:

Key objectives of the study include:

  • To determine the legal and medical consequences to the health of a patient when clinical documentation is not accurate.
  • To evaluate the effectiveness of the clinical documentation in the medical care of a patient.
  • To identify research different suggested and practiced methods to help alleviate improper documentation.
  • To suggest alternative previsions to establish the methods of correcting improper documentation.
  • To evaluate the impact of Health Information management and the services provided by them on patient’s medical care.

Research review:

A consistently discussed topic in recent decades are health care and health informatics, which is known to play an essential role in making consistent efforts to ensure the quality of services provided to patients in any healthcare organization. Clinical documentation is at the core of each encounter of healthcare specifying it to be accurate, specific, legible and timely serving as the key measure for the organizational quality. (A. Jamal, 2018) The review on the health information management mainly focuses on the health of an individual regardless of age. There is a significant need of balancing the requirement of an individual’s health and well-being. (Kapur, 2018 )

As the health information management (HIM) is a practice to acquire, analyze and protect the traditional and digital medical information, which are important for providing quality services of care to the patient. HIM ensures completion, accuracy and protection of the patient’s health information and records. (Hosna Salmani, 2018 ) With the fact, for the management of healthcare information different countries have different electronic systems for health recording purpose such as in the United States, where these health records systems are strictly followed.

On the other hand, previously used records systems were ineffective in functioning,and were highly known for posing many challenges like need of larger space, difficulties in data retrieval as well as an advocacy for the computerized systems. Paper-based systems are more acceptable in legal terms as a documentary evidence tends to be difficult in records tampering with eliminating the need of detection. Health records still require development into a proper process in the delivery system of healthcare, because of the occurrence of cumbersome paper-based and disjointed management systems of health data particularly in the developing nations. (Taiwo, Relevance of health information management (HIM) and the roles of HIM professionals in healthcare delivery systems., 2014 ) But, a Clinical Documentation Improvement Program can provide a tremendous benefit to a healthcare facility.

The advantage of the Health Information Management system is mainly associated with  permitting different countries and partners in development for identification of the key areas of improvement resulting in the improved clinical care and safety of patient, improved communication and co-ordination in care, readmission reduction, reduction in waiting times, and reduction in cost. (WHO, 2008) Although, the performance of HIM system varies in each state with the satisfaction of uploading the data. But, one of the major challenges in the HIM system is considered to be the quality of data with broken rules of validity and outlier’s existence in different variables. (Husain, 2012)

The Health information management system is basically an instrument with numerous applications,such the improvement in the satisfaction of patient with the services of health through tracking certain service quality dimensions. Check of quality through perception comparison of services is known to be delivered with expected standards.Patient’s assessment serves as the concept of providing patients views with significant importance for the improvement of the patients’ service quality.The expected benefits involve anenhancement in the satisfaction of the patient via improved communication,with greater sensitivity provider in the direction of patient. (Shaikh BT1, 2005 )

Maintenance of the interests of individuals in balancing the health information and confidentiality uphold with concerns over security and privacy represents current and fundamental challenges within the legal and healthcare system in the United States. (Prater, 2014)The prevalence of ethical and legal issues in context to the health information management is associated with growth in the technological use in clinical settings. Whereas,the privacy and confidentiality of one’s information is considered important in the electronic system while some issues regarding with use of these systems is primarily known to improve the safety of the patient including changes in the care standards regarding use of electronics despite of medical records on paper, training of users, with assurance of accurate information to provide it to users.

Some other doctrines regarding issues with the use of support tools purposely involve in decision making in clinical practices with an exchange of information in different healthcare institutions, as well as genomic data incorporation in clinical records.(Berner, 2008 ) On the other hand, the communication quality among patients and clinicians greatly influence the outcomes of health. Thus, medical interpreters are required to have an adequate medical terminology knowledge additionally with basic proficiency of language and skills of interpretation. Occurrence of false fluency errors in the medical terminology translation might result in ineffective assessment of patient’s medical history and condition. (Ryoko Anazawa, 2012)……….

 

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