Comparative Inter-professional Assignment Instructions 2022-1

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Liberty University *

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205

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Medicine

Date

Dec 6, 2023

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docx

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4

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Comparative Inter-professional Documentation Assignment Q1. Each student will find an example of a patient documentation from two Allied Health professionals (e.g. AT, PT, OT, Physicians, PA, Chiropractic, Psychiatry, and Exercise Physiologist/Fitness Specialist/Strength & Conditioning). Student will compare how closely the documentation aligns with course content as described by Kettenbach and Schlomer (textbook authors). Student will also compare and contrast between the 2 documents selected. Items like abbreviation, legalism, brevity, errors, HIPAA evidence, well written, and differences in writing style or formatting styles. Q2. How important do you think electronic medical records are for proper healthcare delivery? How important are using abbreviations in medical records and why? Do you feel a fill in the blank type of electronic medical records could miss an important detail related to the patient’s health history and why? Do you feel patients should have electronic medical records in a thumb drive format (or something similar) which is required by the healthcare industry during each medical visit and why? Support your responses with references or critical thoughts. Q1 Provide your answer here (10 points) Q2. Provide your answer here (5 points)
Q3 After analysis of these two documents reflect on your learning discoveries. What have you learned from seeing different styles of documentation? Were you able to identify the patient’s problem based on the provided details within the medical records, explain your answer? How important do you feel the past medical history component is during an assessment and why? What problems could arise for patients who lack details within the documentation system? Two references are required in AMA formatting within the text as well as in the bibliography. Q3. Provide your answer here (10 points) Bibliography (5 points)
The SOAP examples (or other) selected should be placed at the end of the paper as appendix A and B. You may copy and paste or add your documents as attachments with this form. Appendix A (5 points) Appendix B (5 points)
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The purpose of this assignment is to widen the students perspective to various acceptable formats used during documentation. Original health records are acceptable examples but names and identifiers must be eliminated to comply with HIPAA guidelines. This assignment is worth 40 points.