Reflection question: What points in the readings 'stood out' as most relevant to your interests and learning?
Chapter 3 started as a review of the different types of health records, types of documentation standards, and regulating agencies.
Useful points to remember:
1. Basic components of the acute care health record:
Registration record, medical history, physical exam, clinical observations, physician's orders, diagnostic/therapeutic procedure reports, consultation reports, discharge summary, patient instructions, and consents/authorizations/acknowledgements.
We went over each of these types for definition and examples. We used copies of handwritten or paper records to create deficiency slips to determine what information was missing from the records. I believe this easily demonstrates the need for records to be electronic. The writing on many of these was illegible and using a copy instead of an original did not help either.
2. While all health care settings keep similar documentation, some settings of specializations may keep unique documents that are required or needed. Such as: pediatrics compared to hospice care. While they may keep many of the same basic health record components, there may be special sections. Hospice may need a special section on rehabilitation, for example. Pediatrics may need sections on growth and development.
End of week one--