There are five common purposes for medical records. List each of these purposes and provide an example of each in healthcare.
Having good medical records is very important, for the proper care of patients. “Medical records can be used to manage healthcare, track healthcare, provide clinical data, meet regulatory requirements, and document healthcare” (Allen, 2013, P. 57). Without the proper documentation there is no proof that it was ever done. The medical records provide patient information about their health history and personal habits. The patients signed consent forms, advance directive, living will, and DNR would all be found in their medical record.
When we manage healthcare the doctor is able to review the medical
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This information is used to appropriately implement prevention and treatment for patients. The second outcome integrates analysis of information gathered by healthcare personnel to identify trends and inconsistencies within the healthcare population. Through this the origin of problems can be ascertained, and preventive measures can be instituted. Subsequently prevention will decrease incidences and ultimately the cost to
There have been many instances of unauthorized viewing of medical records. Unauthorized viewing of patient records is a violation HIPAA. The HIPAA Privacy Rule requires that “protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function” (Health and Human Services.gov). The case study in which Joe, a staff member accessed medical information after he was allowed access to the hospital to change lightbulbs and the case study in which the daughter of a nurse accessed medical information as a result of the mother leaving the computer unlocked and unattended, are HIPAA violations (i.e both people accessed the medical information illegally). Joe was tasked with changing a lightbulb, but was curious about a patient he knew on a personal level, his neighbor.
1. To make sure the care and treatment can continue to be given safely no matter which staff are on duty, 24 hours a day, seven days a week 2. To record the care that has been given to the patient/client 3. To make sure there is an accurate record to be used as ‘evidence’ when there is a complaint from a patient/client about the
The Physician Assistant (PA) is an essential component of a medical staff. Their duties include, Examining and treating patients, ordering and interpreting diagnostics, educating patients, and promoting overall health and wellness (“Physicians Assistants”. (2015, December 17). Retrieved May 26, 2016, from http://www.bls.gov/ooh/healthcare/physician-assistants.htm). Physician Assistants work in many different areas of medicine under the direct supervision of a primary care physician.
In mental health there are a lot of different roles of different agencies and professionals within the assessments, both of these are for the protection of the service user and service provisions these include mental health services which are set up and run by the NHS organisations as well as some voluntary sectors there are also private companies which are paid for by or commissioned by the NHS. A local GP should be able to recognise a service users symptoms and diagnose the service users symptoms of mental health or psychosis then they should refer the service user to an intervention service were they will then be assessed. These assessments will then be carried out on the service user, which will then provide them with the right services
In care settings the currently legislations, guidelines policies and protocols relevant to the administration of medication would be: - The misuse of drugs act 1971 - The Medicines Act 1968 - Care Standards Act 2000 - The Health and Social Care Act 2001 The Control of Substances Hazardous to Health Regulations 1999 - The RPS Handling Medicines in Social Care Guidelines The recording, storage, administration and disposal of medication must be adhered by employees in accordance with the current policies and procedures. The policies are in place to protect everyone - training must be undertaken or up-to-date before support workers can administrate any medication.
The legislations, policies, processes, and code of practices have established the responsibility of employer in the regulation of social care worker. These standards are being set at the national level as they require the social care providers to comply with them. The codes are important step in the introduction of the system of regulation for the social care within four countries of the United Kingdom. They are required to ensure that people working as social care providers are required to understand their responsibilities. They are required to be provided with the appropriate training to handle vulnerable groups requiring assistance from social care providers.
Many people are supported in their homes by people who work along side the health and social care service such as social workers,nursers ,doctor and care givers or they may get support from their family members and friends. An elderly person may choose to stay in their own homes instead of a residential care home while seeking help and support from others,however this can lead to potential opportunities for abuse happening to the person who Is being looked after. When an individual is getting support at home by a carer, the individual being cared for is vulnerable and defenseless and therefor this makes them a target for abuse,another example is abuse by strangers,when an elderly person lives alone they are at risk of people calling at the door and then gaining access to their homes,they may steal items from them or mistreat them or cause intimidation. A person who is vulnerable and living alone are at risk of physical and sexual because there is no one there to stop this abuse from happening.
If you suspect abuse you must record what has lead to this suspicion, find out any information you can in order to help determine if this is the truth, you must inform other carers, your manager, the individuals care manager and the relevant authorities to ensure that this suspicion to be investigated as soon as possible. For example, an individual I care for with learning disabilities and epilepsy made a phone call to the organisation I work in around 10pm and informed me that she was going out, as it is her right to chose when and where she goes I could not tell her she could not do so, instead I asked where she was going, she informed me she was going to a party at a friends house, I then tried to obtain information about where her friends
In studying Registered Nursing one will find that they have to be compassionate and want to care for others. Registered Nurses assist physicians with suffering patients of any medical condition. They help to decide the patient’s medicine, treatment, recovery, and educate the them and their families on post-medical treatment. They need to have bedside manner, and be able to prepare patients for surgery. Registered Nursing careers range anywhere from critical care, oncology, mental health, to an everyday school nurse.
The responsibilities of an employer and employee under health and safety legislation, was founded in 1974. Act 1974 is a law made to secure the health, safety, wellbeing of people at work and to prevent unnecessary risks. An employer’s responsibilities under health and safety legislation, requires the employer to be responsible for the health and safety of any person in their premises, which includes employees, customers, suppliers and the public. Employers should hire a certified person in charge of health and safety, however in small businesses that person is usually the owner or a trusted member of staff.
It is important to follow any guidelines and leaflets in medication, as this helps the safe administration of all medicines. It is also important to find out if a person has already taken medication prior to the care support worker giving them any. This is to ensure that you do not overdose the individual. A service user usually has a MARS sheet where the medication that is administered in signed off by the care worker that last administered it to them, so that the care support worker can clearly see that last time the medication was administered to service user, and when they are next due to have the medicine.
UNIT 2: EQUALITY, DIVERSITY AND RIGHTS JADA COOPER 20140170 P4: This task will explain 2 different national initiatives, stating when they were set up, the purpose and also how they promote anti-discriminatory practises. It will also talk about Charters and their importance, whilst discussing 2 of the codes of practices’. Care Standards Act 2000 The Care Standards was established in 2000, its’ aim is to ensure that the standards of care within all institutions were not inadequate as the rules and regulations have to be adhered to. The care standards act try’s to make sure that all institutions are equipped and well facilitated to meet the needs of those within the provision.
Health and social care: Unit 7 (P1) Equality and diversity Introduction Farleigh Residential care home is available to the elderly and also it’s a part time day centre for adults with disabilities. Its purpose is to care for needs of adults with learning disabilities and also for the elderly. What is equality? Equality is the idea that everyone has equal rights and every individual is entitled to equality.
World Health Organization (WHO) has defined disability as an umbrella term for impairments. Disability is an individual with a health condition such as Down syndrome cerebral palsy and depression, body functioning or structure on activity limitation. WHO, (2016) supported that people with learning difficulties they deserve privacy and dignity like everyone The Health and community Care Act 1990 protect people service users from abuse or neglect so that deterioration can be prevented or to promote physical or mental health and to allow independence and social inclusion. It also to improve opportunities and life chances, to help families and to protect human rights around people in need of the services. It has been argued Department of health, (2015) state that “people are living longer, which means there are likely to be more people with complex