Documentation Basics in Health Care - Essay Example

"Documentation Basics in Health Care" is a worthy example of a paper on the health system.
Maintenance therapy- a treatment designed in helping the original treatment succeed. Medicaid- is a public health insurance program that provides healthcare coverage to individuals and families with low incomes in the US. Medicare- is federal health insurance for those over 65 years and young people with disabilities, and those in the end-stage of renal disease. Objective data- observable and measurable data obtained through examination and laboratory diagnostic testing. Reasonable and necessary criteria- is the fair and needed support. Reimbursement- compensating for a person who has lost money. Skilled care services- the patient's need for care and treatments. Subjective data- information from the client's view that incorporates how he/she is feeling "symptoms."

The documentation identifies the caregiver reflecting the client’s perspective.

Promotes care to be continued by allowing other caregivers to access the information

Provides a plan of care to the healthcare providers

Demonstrates the commitment of the nurses in the provision of quality services
The healthcare documentation should be factual, consistent, accurate, updated, and provide the patient's current information and state.
The patient telling a therapist that they had diarrhea is subjective data, while the therapist is hearing the patient cough objective data.
To integrate clinical decision-making, determining the probabilities based on the patient’s symptoms and history is vital, gathering valid data, updating it, and considering a proper intervention.
Through their observation and consultation of patients, they document the patient’s responses and progress, making proper decision-making by diagnosing the movement of dysfunction and a treatment plan.
The severity of the signs and symptoms, probability of an adverse or positive outcome from patients, and the therapeutic interventions investigate the patient’s problems.
The problem-oriented medical records should have details on the specific problems of the patient, therapist desired outcomes, diagnosis, and treatment plan.
Skilled care is the patient's need for care or treatment performed by licensed personnel, e.g., during the COVID-19 pandemic, people get professional care. At the same time, maintenance therapy is cancer treatment with mediation, e.g., therapy for a child with walking and talking disabilities at the required age.
PTA records the re-responses of patients for treatment and reports the outcomes to the PT.
Individuals' needs and situations call for the condition of skilled care to facilitate recovery and preventing complications.

Chapter four

Definition of key terms:

Assessment- is gathering information on the patient’s status. The functional outcome reports-defines the care results on the patient’s physical ability. Individualized education plan-describes the set goals for the epical support of children in achieving them. Individualized family service plan- addresses the individual needs of children, their parent's concerns, and early intervention services. Individuals with disabilities education act- American legislation that acters to provide appropriate education to children with disabilities. Narrative-study is showing the experience and interpretation of the world by humans. Objective- a goal. Plan- activities for achieving specific goals by a particular criterion. The problem-oriented medical record (POMR) is a comprehensive approach that records and assesses patients' medical data. The SOAP note-a a documentation method employed by the healthcare providers in writing notes in patients' charts, including other formats. The examiner cannot verify Subjective-is, the patient-reported information, and.

Narrative reports

The problem-oriented medical record

The SOAP notes

The functional outcome reports
Similarities are they are well suited for the differential diagnosis of the patients encounter hence documentation. The core differences are the format differences; for instance, narrative reports are written in paragraphs while tabling a SOAP.
Proper documentation makes the databases more comfortable to use by the therapists and the nurses hence improve the quality of productivity due to easier retrieval of the required information. Furthermore, documentation takes up a lot of space through the filling system and is prone to damage and displacement.
S incorporates the symptoms and stipulates the history. O section documents measurable outcomes concerning the client’s performance. A describes the analysis and interpretation of the client’s progress, and sessions and P stipulates the plan.
The family information might be written as a footnote in the preliminary evaluation and should be a summary.
Entering SOAP notes in the patients' medical report and with the functional outcome reports defines care results focused on the patients' physical ability.
The benefits of templates are; they simplify document creation, save time, and enhances consistency and clarity while the significant drawback is it doesn’t make every visit unique.
Documentation aids in improving processes and ensures consent and expectations. It also tells the decision narrative and shows the patient’s responses hence supporting a proper treatment plan.