HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System
Health Information Management (HIM) organizes and protects patients’ health information that includes symptoms, medical histories, test results, procedures, and diagnoses. HIM is important for providers and other HIPPA entities to make sure data is secure and ensure compliance with government regulations. “The patient’s health care record is the main communication medium between health care professionals, helping them to deliver a high quality of care” (Kamil, 2020) In this assessment I will discuss four different types of documentation used in a hospital or clinical setting.
Progress Notes
A progress note is an ongoing record detailing illness and treatment used in hospitals EHR, clinics, and home health care. Healthcare professionals record notes on services provided, the outcome of the service, and provide updates to other professionals treating the patient. Progress notes ensure continuity of care between team members, especially during a change of shift. Progress notes track medical history and care but can also be used as legal documentation. The information included in a progress report is the patient’s name, date/time, DOB, clinical assessment (vitals, pain, test results), any changes in behavior, any changes in the treatment plan, any incidents, and follow-up instructions for further care. “Nursing activity that has been completed or that will take place should be properly documented. (“Nursing care activities based on documentation – BMC Nursing”) Accurate documentation and reports play a pivotal role in health services” (Hariyati, 2019).
History and Physical (H&P)
Health & Physical documentation is the complete assessment of a patient and the problem they face. Included are the physical exam findings, interview with the patient, and summary of tests pending or obtained. This assessment is critical to identify problems and plan a course of action. H & P is used in all health settings (hospitals, clinics, home health, hospice etc.) without it would be difficult to provide care based on need and evaluate the outcome of care provided.
Operative Report
An operative report documents the details of the surgery and is part of the patient’s medical record. The purpose of the report is documentation and billing. The report includes the name of the surgeon and present staff (assistants, nurses), a procedure performed with a description, findings, estimated blood loss, specimens removed, and post-operative diagnosis. The report should be completed immediately after an operation by a member of the team. “Documentation is read by clinicians as well as claims reviewers from varying backgrounds and experiences; it is important that notes and reports are clear and legible and that they efficiently convey all the essential information that is needed for clinical management and reimbursement” ( (Documentation in Health Care))(ASHA).
Discharge Summary
A discharge summary is a handover that explains why a patient was admitted, and what happened during their time in the hospital. The summary should include patient response to treatment at time of discharge along with any follow-up plan, recommendations, and instructions for home care, and if any equipment is required. “The MD/DO or another qualified practitioner with admitting privileges in accordance with state law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the discharge summary” (Q & A: Can CDI professionals document in the discharge summary?, 2018)(ACDIS, 2018).
In conclusion, proper documentation promotes patient safety and quality of care. Accurate documentation reduces risk exposure to patients and ensures patients get the appropriate care from all providers involved in their care. Poor documentation or loss of information can result in poor outcomes and adverse events for the patient. “In 2005, Joint Commission International ((JCI), 2005)reported that 90% of unanticipated events not related to the patient’s illness that resulted in death or serious physical or psychological injury to the patient were due to breakdowns in communication between health care professionals”.
HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System
References
Asmirajanti M., Hamid A., & Hariyati RT. Nursing care activities based on documentation
BMC Nursing. 18, Article number 32 (2019).
Documentation in Health Care- ASHA
https://www.asha.org
Hariyati R, Delimayanti M. Widayatuti. Developing Prototype of The Nursing Management
Information System in Pukesmas and Hospital, Depok Indonesia. Bus Manag.
2011; 5 (22): 9051-8
Joint Commission International (JCI). Patient Safety; Essentials for Health Care. Oakbrook
Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005.
Kamil, H., Rachmah, R., Wardani, E., & Bjorvell, C. (2020). How to Optimize Integrated Patient
Progress Notes: A Multidisciplinary Focus Group Study in Indonesia. Journal of
Multidisciplinary Healthcare, 13, 1-8. https://doi,org/10.2147/JMDH.S229907
Q&A: Can CDI professionals document in the discharge summary? (2018). Volume 12, Issue 17
https://acdis.org
