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Health Information Documentation


Management

1. What is the importance of a progress note? What information should be included in a


progress note? Why is it important for progress notes to be documented in a timely,
accurate, and legible manner? Your response should be at least 200 words in length.
Progress Notes are generated documentation, relating to the patient and his/her ailment,
in-house, within the hospital. They are important because they serve as a chronological record of
the health care given to the patient from the time of admission, diagnosis and medication given,
the cure and the consequent discharge of the patient from the hospital. They provide a source
from which the quality of care given can be found out, as may be required legally.
It can be said that all the documentation pertaining to the physicians periodical checkups of the patient, be they daily or weekly should be included in the Progress Notes, along with
the condition prior to check-up, change or increase/decrease of prescribed medication, directives
for the Nurses, etc. A typical Progress Note As a minimum, should include an admission note,
follow-up notes, and a discharge note; the frequency of documenting progress notes is based on
the patients condition (e.g., once per day to three or more times per day). Says (Green &
Bowie, 2011, pp.151).
In addition to being a sort of reference Tickler file which helps in complicated diagnosis
of ailments, the second area where Progress Notes will provide a lot of help is in courtrooms in
malpractice cases. With the Progress Notes, one has completely reliable chronological detail
record from admission to discharge. Every detail of the patients checkups by the physician, the
physicians directives to the nurses, The Nurses comments, Medication changes either complete,
or in dose etc. is contained in the Notes. Therefore, it will become an easy matter for any expert
or specialist to come to a conclusion as to whether the treatment provided was competent or not.

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Therefore, it is imperative that the Progress Notes be maintained in an accurate, timely,


and legible manner as they can serve as evidence in a court of law.
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2 Discuss the importance of informed consent. Discuss various types of consent forms
and the reasons they are used. Your response should be at least 200 words in length.
Informed consent along with other similar legal responsibilities on the part of the Health
service provider, came into practice as a documented statute along with other similar actions to
be taken, with the Patient Self Determination Act (PSDA) of 1990. Informed consent is the
process of advising a patient about treatment options and, depending on state laws, the provider
may be obligated to disclose a patients diagnosis, proposed treatment/surgery, reason for the
treatment/surgery, possible complications, likelihood of success, alternative treatment options,
and risks if the patient does not undergo treatment/surgery. (Green & Bowie,2011, pp.129).
It is the objective of informed consent that the patient cannot later file malpractice suits on the
HCP contending that he/she was misled about the post recuperative surgery time, etc. The IC
form comprises of blanks of the variables, which the Physician should fill in, in front of the
patient and then countersigned by both.
The following are similar in nature to the Informed Consent Provision, i.e. they fall
under the Advanced Directive Section of the law, which means the right of the patient to specify
that he /she wishes/does not wish to receive some corollary action of the health care process and
without which too, it is possible to supply health care action. Examples can be
.1. Do Not Resuscitate (DNA) Order :
2. Health Care Proxy (or durable power of attorney):

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Health Information Documentation
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3. Consent to Admission, etc.


These are some of the types of Consent forms.
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Describe each of the forms that comprise a patients administrative data. Explain the
purpose of each form. Your response should be at least 200 words in length.
A patients administrative data contains of the following forms, duly filled in, as per
Green & Bowie (2011, pp. 124). These are
I.
II.
III.
IV.
V.
VI.

Face sheet or Admission/Discharge Record.


Advance Directives
Informed Consent
Patient Property Form, and
Birth certificate (copy) in case patient admittance for delivery and successful childbirth.
Death certificate (copy) in case patient expires in hospital or is declared DOA.
The Face Sheet as in use is not asked for by name by the Joint Committee Standards but

what is asked for is Patients Identification Data. Each page of the face sheet or screen in case of
EMR, should have the patients name or Medical Code on top of the sheet. The Face Sheet
generally has sections corresponding to the patients Personal Information, Demographic
Information, Socio-Economic Information and Financial Information. All these is collected from
the patient at the time of admission and inserted in the Face Sheet. In case some information is
missing at the initial stage, the face sheet has to be made complete within a month of the
discharge of the patient, as per the Joint Committees stipulations.
The Advanced Directive follows from the PDSA act of 1990. It is a legal document
which contains the patients instructions on the health care facilities they want to receive at the
stage when death is inevitable and there is no hope of recovery.

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The Patient Property Form lists the possessions of the patient on admission into the
hospital. Under Informed Consent fall such forms as DNR which has been treated at length in
Question 2.
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Contrast the various types of advance directives available. How do advance directives affect
delivery of patient care? Your response should be at least 200 words in length.

Advanced Directives are those directives that specify how a patient wants healthcare to
be administered, in the final period of his/her life. There are mainly two types of health directives
which are the (a) The Living Will & (b) The Medical Power of Attorney. (Health Care Proxy is
considered same as the MPoA).
A Living Will is a statement in writing by the patient where the health care the patient
wishes to be provided at the stage of incapacitation, is spelled out. For example, a DNR (Do Not
Resuscitate) will fall under this category. This document is called a living will, though it may go
by a different name as per State Laws. A living will is strictly a place to spell out your health care
preferences and has no connection to the patients estate.
The Medical PoA is a durable Power of Attorney for health care, . In this document, a
person whom the patient trusts is made the patients Health Care Agent. When the patient
becomes incapacitated, it is the agent who directs the health care the patient receives.
Advance directives do affect the quality of health care. It can be so that the position
anticipated by the patient, suffers a complete volte-face when the days of incapacitation, finally
come. In the case of the MPoA, the agent can at best be reasoned with but with the living will,

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health care provided has to be as per that described in the will. This surely affects the quality of
the health care offered.
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REFERENCES:
Green, M. A., & Bowie, M. J. (2011). Essentials of health information management: Principles
and practices (2nd ed.). Clifton Park, NY: Cengage

Irving, S. (J.D.) (2016) What Do a Living Will and Power of Attorney for Health Care Cover?
Nolo Legal Encyclopedia. Retrieved http://www.nolo.com/legal-encyclopedia/livingwill-power-attorney-medical-issues-29536.html.