paper task 4
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Western Governors University *
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Course
C803
Subject
Health Science
Date
Feb 20, 2024
Type
docx
Pages
4
Uploaded by AgentTurkey3429
2.The joint Commission and South Carolina have regulations in place to make sure we are providing the best quality and safety in the healthcare settings. One of these areas they regulate is the History and Physical requirements of documentation. I will be comparing similarities between TJC standards and SC regulations.
Both require that H&P examination be completed and documented no more than 30 days or 24 hours after admission. They both require examination to be updated within 24hours after the patient is admitted, and if the H and P was completed within a month of registration.
They both require the H&P and examination to include a review of medications and allergies. To also include patient medical and surgical history. These similarities are to ensure the safety and quality in the healthcare service
3.The joint commission and SC have a few differences when it comes to standards for History and Physical documentation requirements.
Some of the major characteristic of TJC is the timeline as which the papers are to be completed within 24hrs of the treatment. Content should include a detail and comprehensive medical and health history which will include a physical examination and a plan of treatment.
Updates if the H&P was completed in 30 days before the patient admission, you must complete a updated document of any changed in the patient
conditions within 24hrs after admission.
However, SC regulations for timeframe for history and physical documentation should be completed and reported no more than 30 days before
admission. But is required to complete prior to surgery. Content is basically the same concept; you must include a comprehensive medical history and a through examination. Updates if the H and P was
completed in 30 days of services any changes of the patients conditions must be completed within a day of admission.
4.Understanding a patient lifestyle factor can reveal important information regarding the patient
and it could impact their health. This could include
smoking, alcohol consumption, diet and exercise. This can contribute to different health conditions like cancer, heart disease and diabetes. Identifying risk factors can help located genetic or familial risk factors for certain disease. For example, if a patient has a history of breast cancer, they might have a higher risk for the patient. Assessing mental Health can provide a lot of clarify into a patient's mental health. When a patient is under stress, social isolation and trauma this
could contribute to mental health. Like depressing and anxiety.
Social history can reveal social determinants of health, such as education level, living conditions, your social economic status. This can significant impact a person health outcomes. When a healthcare provider understands a patient's history it can help them develop a personalized treatment plan
for example; a patient who has a substance abuse might require a different treatment plan than a patient who doesn’t have a substance problem. 5.The join commission has a guideline for specific standards for completion of H&P documentation.
Standard admissions they require that the documentation is completed in the patient medical records within the first 24hrs of admission. If the patient must undergo invasive surgery, you would need to have the documents completed
first.
Surgical Admission the H&P must be done and documented in the patient's chart before surgical procedure. If the documents was completed
within 30days before admission, you must update the exam of the patient chart. This must be completed and updated in their records
within 24hrs after admission. Readmission is pretty much the same, must be completed within 30days. You are able to use the previous document only if there hasn’t been a change in the patient condition. If a changed has been made than you must updated that in H&P and completed the necessary documents
within 24hrs.
6.The chief complaint is a very important component in the medical history. Its one of the main reason that patient seeks medical attention
Documenting this is important for several reasons:
Establishing the basis for medical evaluation : The chief of complaints helps the healthcare physician in conducting a focused and relevant medical evaluation. This helps determine which test or imaging is necessary.
Formulating a Differential Diagnosis: Along with the patient history of illness, this helps formulate a list of possible diagnosis. This is commonly
known has differential diagnosis.
Creating a Treatment Plan : This is conjunction with the rest of the medical history and exam findings, aids in creating a personalized treatment plan for patient care. Legal Documentation: This serves has a legal document that you can use in the event of a legal dispute of complaint. This proves the patient condition at the time of their visit and the medical care that was provided.
Communication with other Providers: The chief of complaints communicate with other facilities and other healthcare providers. This provides
a concise summary of the patient's problem which will allow for continuity of care. 7.Comprehensive Data Collection which includes patient medical history, physical examination, review of systems and family social history,
all she be capable of collecting comprehensive patient date. Standardized templates for H&P documentation. Having the patient name, date of birth, chief complaint, history of present illness and past
medical history, this would ensure consistency and completeness in collecting data.
Interoperability means the EHR system should be interoperable with other systems to create a seamless date exchange. This is extremely important for coordinated care and compliance with standards.
Security and Privacy ensures that the EHR system complies with privacy and security standards like HIPAA. This would include important
features like access controls, user authentications, and data encryption. Thew system should also have audit trails to track all interactions with patient data. This is very Important for accountability and compliance with regulatory standards.
Training and support would provide adequate training to all users of the EHR system. This would ensure correct and consistent us of the system for H&P documentation.
8.When you are in the healthcare field the organization must stay updated on current changes and state regulation to avoid penalties. Establish a compliance team, someone who is dedicated and would be responsible for monitoring changes in regulations, and would
implement them in the organization.
Regular training and education should be conducted to educate employees about the latest regulations . This can be done through a workshop, seminars, or online courses.
Use of regulatory tracking tools are available that can help organizations stay updated with the latest regulations. This tool provide real
time updated. Regular audits should be conducted to make sure that the facility is in compliance with all regulations and guidelines. If there are any discrepancies found during the audit they should be address immediately. Networking with other healthcare organization and forming partnerships can also help with the
latest regulations. Consultation with legal experts can provide valuable insights into the implementation of regulations. They will also deal with any lega
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