It is the policy of Burnside Hospital (BH) that all patients have a health record that contains accurate, objective, complete and up-to-date clinical documentation that reflects their management, progress and outcomes of care during their hospitalisation.
Clinical documentation in the patient’s health record provides an essential mode of communication between clinicians involved in the care of the patient. All clinicians including Nurses, Midwives, Assistants in Midwifery/Nursing, Physiotherapy Aides, Nursing & Midwifery Students, Accredited Visiting Medical Officers (VMO) and Accredited Allied Health Professionals have a legal obligation to ensure that clinical documentation contains an accurate record of the patient’s condition, treatment and responses to care. Clinical documentations are actually a methodical records of a patient's clinical history and heed. Meanwhile, It contains the information of patient's health included their recognition details, medical background, clinical examination, and codlings data. Good clinical records include;
1) Appropriate medical conclusion should be taken.
2) The decisions made on the basis of record and procedures taken further decided over and above the behaviour of who made the decisions and procedures.
3) The clinical information of patients should be given to them and must keep their record.
4) Furthermore the evidence of several medicines prescribed and the investigations of treatments should be performed.
In good professional practice along with the delivery of excellence healthcare, clinical record keeping seems to be an essential component. The good clinical records are supposed to facilitate with constant care and it should also developed communication among the diverse professional of healthcare. For this, the clinical records must have to be made up to date by all associates of the multidisciplinary group for instance, physicians, surgeons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, chaplains, administrators or students that take part in taking care of patients. It is further important that patients must be given the permission to get access to their records so that they get to know about what has already happened and what is going to happen.
The precise patient record documentation is to further eminence and stability of concern. It should be created the resources of declaration between members and providers as regards healthiness condition, precautionary health services, management, scheduling and liberation of concern. It should be added that clinical documents ought to be truthful, imitate detailed services being given to a patient and well-timed. Moreover, clinical records is second-hand to assist, facts based healthcare systems decisions, data for lawful records and generate patient registry proceedings consequently a public health agencies be capable of management and investigate hefty patient with great numbers added resourcefully. Particularly, health concern providers exploit clinical documentation in case of billing and coding. In a patient’s clinical documents, some healthcare services take up clinical document improvement specialists to assess apiece patient’s clinical documentation and certain there should be no gaps in comprehensive. Clinical records are sort of helpful documents to assess the excellence of healthcare services.
Appropriately, it seems curtail to write the patient’s record but in present time the government tries to the excellence of the medical record. Documentation of patient’s medical record tells the medical history of patient along with present problems and treatment that is given to the patient. It also aids and estimate which treatment can be given to the patient. The permanent documentation of the medical record of patient also helps for the better care of patient in the future. Moreover, it also builds a file that plays significant role in accessing the efficiency of the treatment give to the patient which can be beneficial for research and educational purpose.
Comprehensive clinical documentation within a complete health record ensures that a professional standard of documentation is maintained; appropriate care and treatments are provided to the patient; that there is evidence of patient care; and assists the hospital in fulfilling a variety of administrative requirements.
Every patient accessing care at Burnside Hospital will have a complete health record that:
The documentation will show clear evidence of care given, that appropriate assessment, decision making and implementation of required care has occurred and an evaluation of this has taken place.
Understandable and brief documentation of record is important to give patient excellence care, guarantee precise and on time payment for the services provided, ensuring accurate and timely payment for the services furnish, justifying mismanagement hazards, and accessing the word of healthcare providers and plan the treatment of patient and uphold the scale of care.
Patient Health Records will be regularly audited by the Health Information Manager and Clinical Managers (or their delegates). Audit results will be used for benchmarking against previous performance and external standards and guidelines. Audit results will be reported to the relevant Burnside Hospital committees and area managers for the purpose of ongoing evaluation and improvement of clinical documentation in the health record.
Approved Metric Terminology, Symbols and Abbreviations ATTAC-058
Development of Clinical PathwaysPOL-015
Incident Management Policy POL-062
Application for Access to Personal Records FRM-125
Acknowledgement of the receipt of Personal Health Records FRM-124
Authority to Exchange Information FRM-228
Release of Patient Information Guidelines GUID-027
Privacy Statement – Patient Information Leaflet (as attached)
Offsite Storage Procedure PRC-254
Medical Records Forms Management POL-163
Nursing / Midwifery Clinical Pathways (available on Fast Track)
Accredited Practitioner By-LawsRES-054
Australian Commission for Safety and Quality on Health Care; National Safety and Quality Health Service (NSQHS) Standards. Standard 1 - Governance for Safety & Quality in Healthcare. October 2012
Australian Council on Healthcare Standards, EQuIPNational Standard 14 – Information Management 2012
Australian Nursing & Midwifery Council (2010): National Competency Standards for the Registered Nurse.
Privacy Act 1988
Privacy Amendment (Enhancing Privacy Protection) Act 2012
State Records of South Australia General Disposal Schedule No. 28 – Clinical & Client-Related Records of Public Health Units in South Australia (effective from 19 August 2014 to June 30 2025)
Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help
Proofreading and Editing$9.00Per Page
Consultation with Expert$35.00Per Hour
Live Session 1-on-1$40.00Per 30 min.
Doing your Assignment with our resources is simple, take Expert assistance to ensure HD Grades. Here you Go....