آخـر مواضيع الملتقى

دعــــــاء

العودة  

Issues on Physicians Documentation

ملتقى الجودة وسلامة المرضى
موضوع مغلق
  #1  
قديم 02-12-2011, 11:06 PM
الصورة الرمزية الكفاح
 


الكفاح will become famous soon enoughالكفاح will become famous soon enough


Famous quotes…
If it is not documented it is not there…
In God we trust…everybody else must document!!
Verification of compliance to standards can be done easily through documentation

For patient care, document…
Assessments; initial, concurrent and for follow up
Orders
Medications
Progress notes; MD, RN and AHP
Investigational tests
Operative/Anesthesia/Procedure notes
Medical reports
Consultations
Referrals
Incidents
Health education and advice
For personal use, document….
Credentials
Privileges
CME, CEU
Appraisals
Productivity
Academics
Testimonials (especially pat. sat.)
Utilization data
Presentations delivered
Other accomplishments by month
Example: Medical Record Review
Problem List IDs significant illnesses & medical conditions
Medication allergies/adverse reactions (or NKA) are noted
Past medical Hx easily Identified
Cigarette, drugs noted
Progress notes identify subjective & objective info pertinent to complaint
Lab ordered as appropriate
Working dx consistent with findings
Tx plan consistent with diagnosis
Follow-up care, calls or visits are noted
Unresolved problems addressed in subsequent visits
Medical Record Review
(continued)
Consults requested as appropriate
If consult requested, note from consultant in record
Consult, lab, imaging reports initialed by PCP; if abnormal, f/u plans noted
No evidence pt. placed at inappropriate risk by dx or tx problem.
Immunization record up-to-date on children/adults immunization hx noted
Preventive screening and services offered as appropriate
Notes of phone calls include advice given
Documented evidence of appropriate pt ed about dx and tx

List of Required
Plans for JCIA
QI and Patient Safety
Emergency Preparedness
Strategic Plan
Departmental Plans
Facility Management and Safety
1.Safety
2.Security
3.HazMet
4.Emergencies
5.Fire Safety
6.Medical Equip
7.Utility Systems
Staffing
Management of Information
.Approvals
Other Documents for Survey1
Policies and Procedures (all administrative processes and tasks)
Hospital Organizational Chart
Departmental Policies and Procedures
Medical Records forms and audit reports
List of delinquent medical records

Other Documents for Survey2
Job De******ions of all staff
Utilization Review Program Document/Plan
Credentialing & Re-credentialing Files
Licensure Verification Logs
Infection Control Manual
Incident Reports File
Other Documents for Survey3
Medical Staff By-Laws
Minutes of Executive Staff Meetings
Minutes of QI Committees
Standing Rules
Safety Rules
Educational Programs (QI, IT, Tools) and Participation
Other Documents for Survey4
Written Agreements/Contracts
Hospital Budget
Financial Audits
Laboratory Manuals, Reports and Logs
Pharmacy Manuals, Registries, and Logs
Radiology Manuals, Registries and Logs
e.g. of P&P template
Policy ID (no., date initiated, title, functional area, effective date)
Policy Statement (what?)
Purpose
Scope
Process (procedure; how?)
References (if any)
Attachments/Appendices (if any)
Approvals and Dates

Life Cycle of a Policy..
Policy is drafted, circulated and approved
Policy is communicated (passive vs. active communication)
Policy is implemented
Compliance is monitored (4 months min. track record)
Policy is revised (min. every 2-3 yrs.)
Important items to document..
Governance approves the hospital’s mission statement [GLD.1.1]
Directors identify in writing the services to be provided by the department [GLD.5.1]
Medication errors are reported through a process and time frame defined by the organization. (COP.11.6.3)
The organization establishes a list of those categories or types of treatments and procedures that require separate consent [PFR.9.4.1]
Important items to document..cont.
The scope and content of assessments by each discipline are defined in writing. [AOP.1.1]
The assessment activities performed in different settings are defined in writing. [AOP.1.1]
Assessments are carried out in the time frame prescribed by the organization. [AOP.1.3] (IN ENGLISH)
Every patient admitted has an initial assessment that meets organization policy. [AOP.2]
The organization identifies those patient populations and special situations for which the initial assessment process is modified. [AOP.2.4]
Organization policy defines the circumstances or type of patients for which the reassessment by a physician may be less frequent than daily, and identifies the reassessment interval for these patients. [AOP.3]

Important items to document..cont.
In particular, those individuals qualified to conduct emergency assessments, and those qualified to conduct an assessment of nursing needs are clearly identified. [AOP.4]
For those individuals that perform patient assessments and reassessments, their responsibilities are defined writing. [AOP.4.1]
The organization identifies which laboratory staff members perform testing and which direct or supervise testing. [AOP.5.3]
Laboratory results are available in a timely manner as defined by the organization. [AOP.5.4]
Procedures for the ordering, collection, identification and safe transport, storage and preservation and receipt and tracking of specimens are followed. [AOP.5.7]
The laboratory has established references ranges for each test performed. [AOP.5.8]
A roster of experts for specialized diagnostic areas is maintained. [AOP.5.12]
The radiation safety management program includes written policies and procedures that support compliance with applicable standards and regulations. [AOP.6.2]
Important items to document..cont.
The organization defines the time period for the reporting of diagnostic radiology test results. [AOP.6.4]
There are procedures for the storage, distribution and handling of radioactive, investigational and other drugs and narcotics medications [COP.11.3.4, and Intent]
Written guidelines ensure the complete and accurate labeling of reagents and solutions. [AOP.6.6 Intent
The logs, inspection reports and other Documentation of the monitoring, and corrective actions related to incidents and injuries [FMS.6.1], medical equipment [FMS.7.1], utility system inspection and testing [FMS.9], and water quality monitoring [FMS.9.1].
The facility has instituted a policy or plan to eliminate or limit smoking. [FMS.3.3]
Important items to document..cont.
Organization leaders define the desired education, skills, knowledge and other requirements of all staff members. [SQE.1; 1.1]
The organization defines the level of supervision (consistent with law and regulation), if any, for other health professional staff. [SQE.13-15 Intent]
Uniform diagnosis and procedure codes are used and symbols and definitions are standardized. [MOI.1.8]
Staff has access to the level of information related to their needs and job de******ion. This access is consistent with the organization’s determination of levels of confidentiality and security for categories of data and information. [MOI.1.11]
Documentations must be…
Patient-centered
Comprehensive
Accurate
Reliable, Pertinent, Valid, Applicable
Accessible
Timely
Up to date
Approved
Team preferred
Legible
So, remember…
If it is not documented it is not there!!
منقول
شارك
مشاركة في فيسبوك مشاركة في تويترمشاركة في قوقل بلص


من مواضيعي : الكفاح
موضوع مغلق

مواقع النشر (المفضلة)

الكلمات الدليلية (Tags)
documentation, issues, physicians


مواضيع مشابهه ننصح بقراتها
الموضوع كاتب الموضوع المنتدى مشاركات آخر مشاركة
Ethical Issues الكفاح ملتقى الجودة وسلامة المرضى 2 02-18-2011 02:40 AM
Documentation رانـيـه ج ملتقى التمريض 8 02-01-2011 04:22 AM
كتاب Nursing Documentation طلال الحربي ملتقى التمريض 3 12-10-2010 05:49 PM
FDA Issues New Warnings for Painkillers الصيدلانية مها ملتقى الرعاية الصيدلية 6 05-14-2009 10:03 PM

أدوات الموضوع إبحث في الموضوع
إبحث في الموضوع:

البحث المتقدم
انواع عرض الموضوع

ضوابط المشاركة
لا تستطيع إضافة مواضيع جديدة
لا تستطيع الرد على المواضيع
لا تستطيع إرفاق ملفات
لا تستطيع تعديل مشاركاتك

كود [IMG]متاحة
كود HTML معطلة
Pingbacks are متاحة



الساعة الآن 09:47 PM

ضع بريدك هنا لتصلك اخر المواضيع

ملاحظة مهمه :ستصل الى بريدك رسالة تفعيل بعد كتابة احرف التاكيد
يجب الاطلاع على البريد لاستكمال عملية الاشتراك


Powered by vBulletin® Version 3.8.9
.Copyright ©2000 - 2015, Jelsoft Enterprises Ltd
هذا الملتقى هو مجرد ملتقى لمنسوبي وزارة الصحة ولا يمثل الوزارة إطلاقا
وجميع المشاركات التي تطرح في الملتقى لا تعبر بالضرورة عن رأي إدارة الملتقى
ولكن تعبر عن رأي كاتبها فقط