health care facility must maintain a medical record for each patient that it treats, health and medicine homework help 3-5 pages
Description
3-5 PAGES!!! The Individual and group portion can be 1.5 pages each
As required by law, every health care facility must maintain a medical record for each patient that it treats (Pozgar, 2004). Although the exact specifications may vary slightly across each state, there are still some basic legal principles to remember when dealing with the medical record. As a part of the risk-management department for an assisted living facility, it has fallen to you to take a look at the facilitys policies on medical records.
It is your responsibility to come up with a new policy that deals with the maintenance and release of medical records. Your group will be developing a two-part policy for medical records. The first part will be developed individually and the second part will be developed as a group. The components of Parts I and II are laid out below.
Individual Portion
Medical Records Policy: Part I
Develop Part I of the Medical Records Policy that focuses on the maintenance of medical records. In this section, you should consider things such as the following:
- the contents of a medical record (i.e., what information goes in a record)
- guidelines for properly making an entry in a medical record (i.e., how to do so, how to make a correction, etc.)
Your assignment will be graded in accordance with the following criteria. Click here to view the grading rubric.
Medical Records Policy: Part II
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As a group, develop Part II of the Medical Records Policy. In this section, you should consider issues such as the following:
- ownership of the medical record
- policies/procedures for the release of records
- ways to maintain confidentiality (include any major laws that govern this)
References:
Nursing Standards
Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Clinical Guidelines
Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
BMJ Best Practice
Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/
Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com
Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf
JBI: Evidence summary
Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
JBI: Best practice information sheet
Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
Drug Information
Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm
Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/
Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html
Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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