Comment on the posting of two classmates. The reply posts should be at least 6 to 7 substantive sentences.
Classmate Post 1 (Gladys)
Discussion 3: Impact of Documentation on Patient Care
One of the most essential aspects of electronic health records, along with the interoperability and
portability of the medical files, is the accuracy of documentation. “Documentation contributes to
the patient’s high quality of care, needs to paint a clear picture of the patient encounter, and
should be timely and accurate” (cms.gov, 2024). The Exploring Electronic Health
Records textbook instructs that documentation steps consist of an on-going cycle that begins
with the first patient encounter, leading to the assessment and then the care plan, progress notes,
and reassessment. The cycle continues until the patient has reached wellness goals.
During the assessment step of the documentation cycle, the patient’s history and physical
examination is conducted. The assessment phase of the documentation cycle is critical, as the
chief complaint and the review of body systems are documented at this stage. The accuracy of
documentation aids the physician in making errorless treatment decisions for the patient’s quality
plan of care and assures that proper coding and billing is reported. Following the assessment
step, the care plan is developed, and goals are established to meet the needs. The care plan step
of the documentation cycle is the road map to the patient’s health (Maryland.health.gov, 2016).
Inevitably, the care plan is what the clinical team will reference to provide treatment to the
patient while leading the patient towards achieving expressed health and wellness goals. The
clinical team references the care plan for pain management, ambulation and eating needs, and
therapies treatment. The responses to the care plan are documented in the progress notes.
Documentation in the progress note can ultimately impact the patient and cause negative
outcomes if the progress notes are not up-to-date, timely and accurate. There should not be any
ambiguity within the progress notes, which is where the clinical team provides updates regarding
the patient’s condition and should not be copied nor cloned. According to the Centers for
Medicare and Medicaid Services (CMS), “medical record documentation is required to record
pertinent facts, findings, and observations about an individual’s health history including past and
present illnesses, examinations, tests, treatments, and outcomes” (health.maryland.gov, 2016).
Thus, all aspects of the documentation cycle have a direct impact on the patient’s quality of care.
References:
Center for Medicare and Medicaid Services. (2024). https://www.cms.gov/
Foltz, D., Lankisch, K. (2022). Exploring Electronic Health Records. (3rd Ed.). Paradigm
Education Solutions of Kendall Hunt.
Maryland Local Health Department – Billing Manual. (2016). Clinical Documentation and
Coding. https://health.maryland.gov
Classmate Post 2 (Djonta)
The documentation cycle is a critical component of providing high-quality healthcare. It
encompasses the creation, maintenance, and utilization of several types of documents, such as
medical records, care plans, and communication logs (Foltz and Lankisch, 2022). Each stage of
the documentation cycle has a direct or indirect impact on patient care. Here is a brief overview
of how each step affects patient care:
•
Data Collection:
Impact on Patient Care: Accurate and comprehensive data collection is the foundation of
effective patient care. Clinicians gather information about the patient’s medical history, current
symptoms, and relevant demographics. This step ensures that healthcare providers have a
complete understanding of the patient’s condition and can make informed decisions about their
care (Colling et al., 2019).
•
Documentation Creation:
Impact on Patient Care: As explained by Carrieri et al. (2018), creating detailed and organized
documentation is essential for communication and continuity of care. Medical records, care
plans, and other documents serve as a reference for healthcare professionals involved in the
patient’s treatment. Well-organized and clear documentation reduces the risk of errors and
ensures that all team members have access to up-to-date information.
•
Information Sharing and Communication:
Impact on Patient Care: Effective communication is critical for coordinated and safe patient care.
Sharing information through documentation helps care teams collaborate, leading to betterinformed decisions.
•
Legal and Regulatory Compliance:
Impact on Patient Care: Adherence to legal and regulatory standards in documentation is crucial
for patient safety and care quality. Compliance ensures that healthcare organizations maintain the
confidentiality and privacy of patient information.
•
Auditing and Quality Improvements:
Regular audits of documentation contribute to quality improvement initiatives. By identifying
areas for improvement or potential issues through documentation analysis, healthcare
organizations can implement changes to enhance patient care processes. This iterative feedback
loop helps in maintaining and improving the overall quality of care.
In summary, the documentation cycle in healthcare is a continuous and dynamic process that
significantly influences patient care. Accurate and timely documentation supports
documentation, collaboration, legal compliance, and quality improvement, ultimately
contributing to the delivery of safe, effective, and patient-centered care.
References:
Carrieri, D., Briscoe, S., Jackson, M., Mattick, K., Papoutsi, C., Pearson, M., & Wong, G. (2018,
February 2). ‘Care Under Pressure’: A Realist Review of Interventions to Tackle Doctors’
Mental Ill-Health and its impacts on the clinical workforce and patient care. BMJ Open.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829880/
Colling, R., Pitman, H., Oien, K., Rajpoot, N., Macklin, P., Snead, D., Sackville, T., & Verrill,
C. (2019). Artificial Intelligence in Digital Pathology: A Roadmap to Routine Use in Clinical
Practice. The Journal of Pathology, 249(2), 143–150. https://doi.org/10.1002/path.5310
Foltz, D., & Lankisch, K. (2022). Exploring Electronic Health Records. Paradigm Educational
Solutions.
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