Question

1. Authenticated, accurate, legible, complete and timely documentation is paramount to patient safety, quality of care provide to those patients, and appropriate reimbursement. Define the underlined terms related to the documentation in the health record.

2. What is the role of the Physician's documentation?

3. What is the role of the Nurse's documentation?

4. List 3 job functions HIM professionals use in record documentation.

Answer 1

Authenticate=exact and correct; without mistakes

Accurate=to produce evidence to show thatsomething is genuine, real or true

Timely and complete ,accurate documents are safe becomes patient take proper and effectively care and safe from any mistakes in care

2-documentation in the physician workflow is an easy way to assist clinicians and also provide accurate capture of the diagnosis. Diagnoses such as decubitus ulcers or malnutrition are often found in documentation from other clinical providers such as nurses or clinical dieticians.

3Quality nursing documentationplays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.

4

There are four major focus research areas in informatics education reflecting various disciplines:

1. Medical/Bio Informatics—physician- and research-based; attracts medical students
2. Nursing Informatics—clinical- and research-based; attracts nursing students
3. Public Health Informatics—public health- and biosurveillance-based; attracts public health students
4. Applied Informatics—addresses the flow of medical information in an electronic environment and covers process, policy and technological solutions; attracts HIM students