PPT-Health History And Documentation

Trisha Economidis MS ARNP LakeSumter Community College What is a Health History Part of a comprehensive nursing assessment Subjective data Your Patients Story Interviewing Techniques. Cheryl Bernknopf R.N., BScN. Assistant Director Centauri Summer Camp. Co- Chair OCA Healthcare Committee. Board Member of the ACN. PURPOSE. To provide the multidisciplinary team with a structured note format for documenting. EMS Documentation Uses. Legal record. Continuity of care with hospital. Internal quality assurance. Billing record. Today’s Environment. Government focus on fraud. Increased audits. Legally collecting every dollar . For Charter Educators . Sara . Hardner. Leon. Powell & Leon, LLP. Austin, Texas. The Objectives of Effective Documentation. The primary objective for creating effective employee documentation is to:. ethical, legal and clinical issues. Margaret . BROWN. Research . Fellow, Hawke Research Institute, University of South . Australia. Ravi RUBERU. Geriatric . Registrar, Royal Adelaide . Dr. Andrew Wallace PhD . BEng. (hons) . EurIng. andrew@cs.umu.se. Overview. Documentation. Javadoc. More documentation. Documentation. Document your program. For others. For yourself. Programs change over time. Sara . Hardner. Leon. Powell & Leon, LLP. Austin, Texas. Overview. Documentation of personnel concerns. Employment Law Overview. Documentation Best Practices. Why Document Personnel Concerns?. Provide the employee with fair feedback on his/her performance;. California Department of Aging. Documentation Rule #1. Documentation. Utilizing the Participant Form Checklist. Official Document or . Business Record. Confirmation of . Signature and Date. Make sure that forms are . Documentation tells a story. Quality documentation tells a story that everyone can understand. What does your documentation say about you? . Financial implications. Documentation is a receipt, warranty and guarantee for payments received.. Case . Examples & . Highlights. When Documentation Gets in The Way of the Defense. Presented By: . Joanne . Gulliford Hoban. Morrison . Mahoney, LLP. Case #1 – Emergency Department . Example of documentation in ED by both MD & RN. RCPA Conference. October 8, 2014. Agenda . Behavioral Health Services Cultural Overview. Current Regulatory Environment – New Compliance Challenges. Function of the Progress Note. Defensive Maneuvers – Audit Proof Documentation. ICD-. 10. . State. a. cuity. type . Acute . Chronic. Classification. . Paroxysmal. Persistent. Chronic or permanent . 4/16/14cditipsheet. Most important documentation requirement . for diagnoses. Jan Malone 8. th. floor Nurse Educator. Importance of Documentation. Helps us track our patient’s progress. Conveys information between disciplines and shifts. Can determine therapy. Is part of the permanent record. Adherence to clinical practice guidelines (CPGs) is key to quality of care delivery. . Evidence-based practices for rational antibiotic use are difficult to monitor in private primary healthcare facilities in LMIC settings. . Update CSS Guide for PeopleSoft Fluid User Interface May 2015 Oracle PeopleSoft PeopleTools 854 Product Documentation Update PeopleSoft Fluid User Interface Copyright 2015 Oracle and/or its aff