A hospital can be a confusing and overwhelming place, especially for patients who are not used to being in a medical setting. It is important for patients to be aware of the potential for missed or incorrect information when they are in the hospital. Here are some tips on how to avoid missing important information in the hospital: 1. Pay attention to your surroundings. It can be easy to get distracted in the hospital, but it is important to pay attention to the information that is being communicated to you. 2. Make sure you understand the information that is being given to you. If you are unsure about something, ask questions. 3. Keep a list of questions. If you have questions about your care or treatment, write them down so that you can remember to ask them later. 4. Keep a list of the medications you are taking. This can be helpful if you have questions about your medications or if you are discharged from the hospital and need to take your medications with you. 5. Make sure you have a copy of your discharge instructions. These instructions will include important information about your care after you leave the hospital. Following these tips can help you avoid missing important information while you are in the hospital. Paying attention to your surroundings, asking questions, and keeping a list of questions and medications can help you make sure you understand your care and treatment.
How Can You Protect Patient Information?
It protects your health information and establishes rules and limitations for who can view and receive it, as well as other rights and protections. It applies to all forms of protected health information, including electronic, written, and oral records.
The black market value of healthcare records is far greater than the value of other records hacked. The access, storage, and distribution of patient records are the most common areas of cyber exposure in the health care industry. As a result, the high value is probably driven by the massive amount of personally identifiable information that is kept in its records. The covered entities may face significant federal, state, and civil liabilities if a breach occurs. Anthem has settled a record HHS cyber breach case for $16 million. According to the Healthcare Information and Management Systems Administration (HIMSS), 707 healthcare organizations reported data breaches of 500 or more patient records during the 12 months ending August 31, 2021. Data transfers between organizations and inactive databases should be included in encryption. Your data should be encrypt with AES- 256 as a general rule if it is to be secure. When properly encrypted data is involved, breach notification exceptions are usually provided by the state.
How Can Nurses Prevent Documentation Errors?
Nurses can avoid making documentation errors and may face legal consequences by adhering to best practices.
Knowing how to accurately document a patient can mean the difference between life and death for them. If an employer fails to properly document his or her work, he or she may be held liable for malpractice and other legal issues. Electronic medical records (EMRs) allow physicians to store their patients’ paper charts in digital form. These apps are simple to use, search for, and update, and they include reminders and alarms that can be set. Every day, one person in the United States dies as a result of a medication error. Every year, over one million people are injured by medication errors. If your handwriting is sloppy or out of place, you may receive mixed messages about your patient’s history and directives.
If an incorrect diagnosis is made, the patient’s care may suffer. A nursing documentation error can occur if nurses are not comfortable with and proficient in electronic medical records (EMRs) or electronic health records (EHRs). According to a study, there are 13 skill gaps in nursing documentation. The use of academic EMR training in nursing classrooms allows instructors to educate students about the technical aspects of an EMR. Academic EMRs can assist nursing students in understanding how to properly submit documentation. The use of an EMR improved students’ charting performance, critical thinking skills, and the readiness they would need for practice after graduation. Lippincott DocuCare is an application that improves clinical learning by incorporating real-life patient care scenarios into the application.
Nurses: Be Sure To Document Patient Information Accurately
Inadequate documentation can lead to inaccurate patient records that can have a negative impact on the patient and nursing staff. It is critical that nurses document patient information accurately and legibly in order for it to be used for determining the severity of illness, the intensity of care, and the quality of care provided.
