Essay Sample on Healthcare Documentation: Ensuring Best Care for Patients

Introduction

In healthcare service provision, healthcare providers must document the management of a patient, which include the condition and the history of care. Documentation of such information ensures that patients receive the best services available since all caregivers attending to the patients are able to access the information. Doctors rely on record-keeping when evaluating the profile of their patients, analyzing the treatment and recommending the right treatment. However, if such information is not kept properly, it may result in negative impacts on the patients. This may be as a result of the emergence of documentation issues and breach of patient confidentiality.

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There are various documentation issues, such as missing or incomplete documentation of the patients' record. In the case where this issue occurs, subsequent care providers after the first provider who recorded the patients' information cannot locate the complete records. The issue is critical since offering further treatment and care to a patient may be a challenge for lack of proper documentation that shows the profile of the patient (Thomas, 2009). Another documentation issue involves misplaced or conflicting information. Misplacement of information is common in hybrid health record environment and is a major problem in the management of the health information (Thomas, 2009). For example, having the procedure notes end up in the portion of the progress notes. Further documentation issues are related to the carelessness in copying and pasting of the information and mixed messages that affect the proper way of documenting information.

There are other documentation issues of the records that are related to the general errors that are made by health providers. Sometimes, important notes may not be available, and this happens in many cases when the doctor does not write down all conversation with the patient. The issue also aligns with the inadequacy of taking the history of the patient (Embi at el, 2004). In this case, it is a challenge for other providers to understand the treatment profile of the patient. Issues such as leaving some fields, black and careless handwriting are critical and should be addressed when documenting to avoid challenges in offering proper and quality healthcare to the patients.

According to the Joint Commission website, there are medical abbreviations which are permissible or prohibited for use by the commission. The list of the abbreviations that are not recommended for use by the Joint Commission was established in 2001. The development of the list was aligned with the intention to meet the goal of National Patient safety. Even after the list was developed to identify the recommended and prohibited abbreviations, the commission urges health providers that they review the abbreviations in a regular basis to ensure that risks are reduced and prevent the errors that occurs inpatient care.

According to the commission, healthcare providers are not supposed to use 'U,u' but instead write "unit" since it may be mistaken for "o" or the number 4. The use of IU is also prohibited and instead recommends that providers write International Unit since one may mistake it for IV or the number 10. Other prohibited abbreviations include the use of Q.D, QD to mean daily and use of Q.O.D, QOD to mean every other day and recommend that providers write either daily or every other day. This is because one may easily mistake Q and O for I. The commission also prohibited the use of MS or MSO and recommend that providers write morphine sulfate or magnesium sulfate.

References

Embi, P. J., Yackel, T. R., Logan, J. R., Bowen, J. L., Cooney, T. G., & Gorman, P. N. (2004). Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. Journal of the American Medical Informatics Association, 11(4), 300-309. Retrieved from: https://academic.oup.com/jamia/article-abstract/11/4/300/974728

Joint Commission (2018). Use of Codes, Symbols, and Abbreviations. Retrieved from: https://www.jointcommission.org/

Thomas, J. (2009). Medical records and issues in negligence. Indian journal of urology: IJU: journal of the Urological Society of India, 25(3), 384. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779965/