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How to Save Professional Medical Release in DOC

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A Houston woman, Ethel Easter, secretly recorded her surgery to capture comments made by the doctor and staff regarding her appearance and personality. She hid a recorder in her hair extensions before a hernia operation and later expressed feeling violated upon hearing disparaging remarks about her body while she was exposed during recovery. She was particularly offended by a comment she interpreted as racially profiling, comparing her to a character from the movie "Precious." Easter made the decision to record her surgery following a tense meeting with her doctor, Kenton. The case has raised concerns about patient privacy and the behavior of medical staff.

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What is poor documentation?

What is poor documentation? In general terms, its anything that prevents the clear presentation of information. It lacks clarity, accuracy or the specificity required to deliver data in either written or electronic form.

How do you store medical records?

Cabinets with locks, for example, are a must. The larger your practice or medical facility, the larger your storage area will be. Thus, you may need to store them in a locked room or even a locked building. Storing paper medical records in a climate-controlled storage unit covers all of these necessities.

How long is a medical record release Good For?

Theres no statutory time period within which a release must expire. However, under HIPAA, an authorization to release medical information must include a cutoff date or event that relates to whos authorizing the release and why the information is being disclosed.

What are the common documentation errors?

Common types of documentation errors in healthcare include misspellings, incorrect dates, transposed numbers, and omitted information. Incomplete or illegible handwriting can also cause problems. In some cases, an error in one part of a document can invalidate the entire document.

What are three examples of poor documentation practices in patient records?

Sloppy or illegible handwriting. Failure to date, time, and sign a medical entry. Lack of documentation for omitted medications and/or treatments. Incomplete or missing documentation.

What medical papers do I need to keep?

Keep these records at the ready. A personal health history (conditions, how theyre being treated and how well theyre controlled, as well as important past information such as surgeries, accidents and hospitalizations) Doctor visit summaries and notes. Hospital discharge summaries.

What are three 3 factors that lead to errors in documentation related to medication administration?

Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors. Contributing factors to patient and caregiver error include low health literacy, poor providerpatient communication, absence of health literacy, and universal precautions in the outpatient clinic.

What is improper documentation?

If documentation doesnt give a clear presentation of a patients history, it is termed improper documentation. Thus, this study aims to determine the level of patient documentation practice and ascertained the technical knowledge possessed by health record staff practicing documentation.

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Save Professional Medical Release in DOC