Patient Care System Clinical Documentation

Found 7 free book(s)

Quality, Patient Safety, - Stanford Health Care

stanfordhealthcare.org

Clinical Documentation – Key Points The EMR must only contain factual and objective information pertaining to direct care of the patient and/or relevant conversations with patient/patient family. Current/complete records aid diagnosis and treatment; communicates pertinent information to other caregivers. Appropriate documentation:

Patients, Quality, Safety, Clinical, Care, Documentation, Clinical documentation, Patient safety

Seven steps to patient safety The full reference guide

www.publichealth.hscni.net

Seven steps to patient safety is most relevant to staff responsible for clinical governance and risk management, including executive and non-executive leads. W e also encourage all staff who provide care in the NHS to use it as a patient safety manual. This includes those working in any care setting (primary, secondary and tertiary care, acute

Patients, Clinical, Care

Evaluation and Management Services Guide

www.cms.gov

Clear and concise medical record documentation is critical to providing patients with quality care and is . required for you to receive accurate and timely payment for furnished services. Medical records chronologically . report the care a patient received and record pertinent facts, findings, and observations about the patient’s . health ...

Services, Patients, Management, Evaluation, Care, Documentation, Evaluation and management services

Quality ID #134: Preventive Care and Screening: Screening ...

qpp.cms.gov

Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status ) Numerator Instructions:

Patients, Screening, Care, Documentation, Preventive, Preventive care and screening

Age-Specific Considerations in Patient Care - RN.com

lms.rn.com

specific assessment and documentation tools to assure that these risks are addressed. In some aspects of care, your actions vary greatly with the age of the patient: • Performing physical assessment and interpreting the findings • Administering medication • Assessing and addressing nutritional status • Communicating

Patients, Care, Documentation, Specific, Care patient, Age specific

Chronic Care Management - AAFP Home

www.aafp.org

Documenting Time What Time Counts? •Reviewing labs, x-rays, and consultant notes •Arranging referrals, speaking to home health nurses, etc. •Answering patient phone calls/emails about ...

Patients, Care

Care of the Adult Patient with Down Syndrome - SMA

sma.org

on the comprehensive care of adult patients with Down syn-drome. Guidelines for the care of pediatric and adolescent patients with Down syndrome have been discussed more thor-oughly elsewhere.3Y6 Patients with Down syndrome are at risk for the same conditions as the population without Down syn-