Question.1474 - Week 6: Discussion - Health Care Settings James Lewis 77 unread replies.1818 replies. Week 6: The hospital inpatient record includes administrative data (e.g., demographic, financial, socioeconomic), which is gathered upon admission of the patient to the facility. Reports that comprise administration data include the face sheet (or admission/discharge record), advance directives, informed consent, patient property form, and birth certificate. When a patient is admitted to the hospital through the ED or ER, the first clinical data item is the chief complaint documented as part of the ED/ER record. Other clinical data documents include the discharge summary, history and physical examination, consultation, progress notes, nurses’ notes, and so on. Discuss the importance of obtaining a complete set of admission records described above. Why, or why not, is obtaining the documented chief complaint necessary before a patient can be treated! Discuss the potential for someone receiving either appropriate or inappropriate care should the chief complaint is missing or not sufficiently documented. Discussion Guidelines: Each week you will have a topic to answer and then respond to at least two classmates. This means, that if you follow the minimum posting requirements you will have one main substantive answer in each thread, and one response to at least two classmates. Altogether 3 posts, 2 of which will be on different days of the week. Be sure to check in if you have questions. Grading rubric for discussion posting per thread: Main post - 10 points (high quality) Response posts - 10 points (total of all responses) Post by Wednesday - 5 points
Answer Below:
The importance of obtaining a complete set of admission records is: Patient Assessment- A complete set of admission records helps in detailed patient assessment as it provides the complete medical history of the patient and other related information which helps in customization of the treatment to be given to them. Legal Compliance- It is important to maintain complete set of records so as to comply with various legal requirements prevailing in the healthcare system. It reduces the risks which are associated with non-compliance of legal requirements. Billing Process- The admission records play a significant role in billing process. It provides the detailed information about the information coverage and helps in reimbursement process of the patient. Obtaining the documented chief complaint is necessary before a patient can be treated is necessary because firstly, it ensures the safety of the patient as treatment on priority basis are provided to the patients who have serious complaints. Secondly, it helps in planning the entire process of the treatment to be provided to the patient as different patients have different medical needs, so the treatment needs to be planned well in advance. A documented chief complaint serves as major evidence of compliance with legal and regulatory requirements. If a proper documented chief complaint is missing, there are high chances of patient receiving inappropriate care. Due to lack of proper documentation, the medical team might struggle to provide the proper diagnosis to the patient. In the cases where the patient is unable to communicate his or her problems clearly, the absence of chief complaint might lead to health complications of the patient. Therefore, it is important to have a proper documented chief complaint so that there is no miscommunication between the healthcare team members and correct diagnosis can be given to the patient. References Verhovshek, J. (2018, June 7). Chief complaint is a must have - AAPC Knowledge Center. AAPC Knowledge Center. https://www.aapc.com/blog/42585-chief-complaint-required/#:~:text=The%20CC%20is%20the%20reason,necessary%20to%20evaluate%20the%20patient.More Articles From Strategic Management
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