Question

list the responsibilities of various health care providers to support the documentation requirements in the Medical Record. From the time of admission to time of discharge.

List 10 health care providers/disciplines or administrative health care workers and differentiate their roles and responsibilities to support documentation requirements

Answer 1

Medical records documentation carries a great means of responsibilities for the patient, as the record is the only link of communication as the documentation is to foster quality and continuity of care. It creates a communication between providers and between providers and members about health status, preventive health services, treatment, planning, and delivery of care.

Medical record standards reflect the importance of confidentiality and accessibility by authorized users.

The list of responsibilities for the documentation requirements in the Medical Record are listed as under :

• To keep individual record for each patient
• To establish an organized record-keeping system to ensure that medical records are easily retrievable for review when needed, at each patient visit.
• To store and maintain medical records in a centralized and secured location that can be accessed by authorized personnel and provide equivalent security for medical records.
• To maintain and organize documents within medical records in a specified order.
• To ensure that documents are fastened securely within a paper medical record.
• To provide training in confidentiality and security for patient information.

Whenever provider, other than a member's personal physician sees a complete documentation, of the encounter, it must be available to the referring provider and the member's personal physician. If the documentation is not added directly to the medical record, copies of the relevant medical records must be provided within a specified working days of the visit.

Promptly forwarding the records ensures that the personal physician has a complete medical record on file and that the referring provider has necessary information.

Documentation standards reflect the importance of complete, timely, and accurate health information.Member identifiers appear on every piece of documentation. Entries are legible and are recorded in black ink if on paper. Entries are dated and authenticated by the author. Respective documents are made at the time service is provided. Documents must be supported by all codes. All standard medical abbreviations should be used in documentation. All patient details, including telephone, fax, and electronic message exchanges must be documented. Documentation of any advance directives is in a prominent part of a member's medical record and includes whether or not a member has executed an advance directive, documentation of any information about advance directives that was made available to the member

Documentatio must include the problem list, including significant illnesses and medical conditions, medications, adverse drug reactions, allergies, smoking status, any history of alcohol use.

Important personal data such as patient’s history, physical exams, documentation of clinical findings by the physician and evaluation for each visit. Laboratory and other studies that are reviewed. Working diagnoses with findings and test results.

A detailed treatment plans consisting with diagnoses a follow-up plan for each encounter should be mentioned. Previous problems should be mentioned in follow-up visits.