Documentation in clinical settings is an integral component of the healthcare professional's duty. Good record keeping is crucial for quality patient care and effective communication amongst healthcare providers (U. S. Department of Health and Human Services Health Resources and Services Administration, 2011, April). Within a multidisciplinary team, nurses and other healthcare providers, it is mandatory to share information regarding patients and organizational functions in an accurate, timely, concise, concurrent, thorough, confidential, and in an organized manner. Information is conveyed verbally or in written and electronic forms across all settings. Electronic and written documentation are formats that give long-lasting and retrieval records. Electronic Health Record (EHR), a form of electronic records, offers an integrated, real-time process of providing an updated status of patients to other healthcare professionals ( McGinnis, Malphrus & Blumenthal, 2015) . Information such as patient assessment, clinical problems, medication records, clinical parameters, and how patients respond to treatment must be timely documented in a patient's EHR to aid the ability of healthcare providers to make informed decisions and provide quality care to patients. Poor record keeping is a health risk to a patient and may have a detrimental effect on a patient, such as a morbidity or mortality.
In the United States, The Agency for Healthcare Research and Quality (AHRQ) is one of the twelve agencies within the Department of Health and Human Services that is concerned with the quality of care provided to patients and patient safety ( Courtlandt, Noonan & Feld, 2009) . The mission of AHRQ is to enhance safety, quality, effectiveness, and efficiency of care for all Americans. The agency was created in 1989 and has since then focused on multiple strategic objectives pivoted on promoting optimum research methods and publicizing the best accessible research outcomes to policymakers and healthcare providers. AHRQ endeavors to offer evidence-founded data on healthcare outcomes, access, standards, and cost to enable individuals in critical scenarios to make more informed decisions and enhances the quality of healthcare services.
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Response: Student 1
I agree with Jora that a medical record is a communication tool informing the roles of healthcare partnership between providers, health insurance, payors, and other allied partakers on care delivery. Patient documentation avails information on treatment plans to ensure all the stakeholders strategize on patient care and how the services provided will be reimbursed. Also, it is pertinent that the EHR be accurate and updated to avoid medical errors, which may have adverse patient outcomes and costly too. The Agency for Healthcare Research and Quality (AHRQ) ensures patient safety by reviewing care quality by different providers and implement policies that promote standard care.
Response: Student 2
I concur with Kevin on the usefulness of proper documentation in healthcare. Correct record keeping is fundamental, and the moment it is compromised, the patient's health is at risk. Electronic Health Records (EHRs) contain patient information regarding medication and history when data privacy is jeopardized; there is a higher chance that it may land into the wrong hands. Fundamentally, the United States Department of Health and Human Services Health Resources and Services Administration is one of the agencies that provide healthcare documentation with primary objectives of accountability and safeguarding of data.
Reference(s)
Courtlandt, C. D., Noonan, L., & Feld, L. G. (2009). Model for improvement-Part 1: A framework for health care quality. Pediatric Clinics of North America , 56 (4), 757-778.
McGinnis, J. M., Malphrus, E., & Blumenthal, D. (Eds.). (2015). Vital signs: Core metrics for health and health care progress . National Academies Press.
U. S. Department of Health and Human Services Health Resources and Services Administration (2011, April). Managing data for performance improvement.
