ARISE Nursing Newsletter August 2017

ARISE NEWSLETTER ISSUE 05 | AUGUST 2017

MEDICAL RECORDS DEPARTMENT

INSIDE THIS ISSUE

NEED OF MRD?

INTRODUCTION TO MRD

ROLE AND FUTURE PLANS OF MRD

DOCUMENTATION DO’S

AND DONT’S

Why Do We STILL EXIST? In organization like UHS that’s adopting Electronic Medical Records, this question is in minds of a lot of staff who are wondering why we need department for medical records. Therefore, if you want to dispose this query, please continue reading!!

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ARISE Newsletter | August 2017

INTRODUCTION Medical Record Department occupies one of the most important places in hospital. It is the hub of hospital, which connects other departments together. It is Medical Record which protects any hospital from Court of Law, and gives the data and information to present a paper in conference and also to ministries for future planning and projection. MRD plays important role in providing information on monthly and yearly basis to Director and Ministry of Health for evaluation of performance. It is Medical Record Department which helps and facilitates Researchers in conducting medical research for their Thesis purposes.

MRD Ensures Continuity of Care for the

PATIENT ARISE Nursing Newsletter from University Hospital Sharjah

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ARISE Newsletter | August 2017

MRD CURRENT ROLE: 1.

Medical Records Department is responsible maintaining, storing and retrieving patient health information in accordance with applicable MOH regulation, and accrediting agencies' requirements.

2.

Develop medical records systems, recommend, implements and modifies policies and procedures which complies with licensing and federal regulatory guidelines.

3.

Participates in the development and implements policies to preserve the confidentiality of information contained in the medical records and monitors compliance.

4.

Provides and coordinates a system for safeguarding and updating active and inactive patient medical records.

5.

To maintain high quality of documentation according to JCI standards, MRD is responsible to monitor overall compliance of documentation policy of authenticated staff who are making entries in the records.

6.

MRD provides MOH with different kinds of statistics and registries like cancer registry, diabetes registry, cardiovascular

disease registry and any other statistics required.

7.

Provides the managers, physicians and other departments with statistics according to their needs.

8.

Releasing of patient medical information and maintaining the privacy of this information is one of many tasks that MRD handling.

9.

Improving the quality of services by conducting ongoing quality improvement project like automatic releasing of some reports through patients’ emails, E-signature etc.

10. Orientates new staff to the relationship and interaction of medical records unit with other units of the facility 11. Follow up of patients’ requests in terms of Medical Report to finish it within time frame.

12. Suggested revisions to existing forms and developed new forms when necessary 13. Promotes the development of the Medical Records department, through scan at source projects, elimination of paper records through conversion to electronic.

ARISE Nursing Newsletter from University Hospital Sharjah

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ARISE Newsletter | August 2017

FUTURE

ROLE & PLAN 1.

Increase the awareness of coding and pprovide development and guidance on the locally agreed coding mechanisms through continuous training.

2.

Provides ongoing training on documentation standards according to JCI requirements and UHS policies.

3.

Conducting ongoing re-audit of open records through rounds in all wards and clinics.

4.

Evaluates compliance, implements corrective action on areas needing improvement or re-training.

ARISE Nursing Newsletter from University Hospital Sharjah

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ARISE Newsletter | August 2017

Documentation

DO’S Document only after patient is assessed, cared and after procedure

Write legibly, clearly, and use correct spelling

Document the day, month, year, and time of each entry

It must meet the requirement of the institution, support your documentation with facts

Document in an accurate and timely manner

Document all care related communications with patients

Initial each chart entry

Include positive as well as negative changes in the patient’s condition.

Document non-compliance

Use hospital approved abbreviations

Document allergies

Document instructions given to the patient

Addendum to the medical record should be clearly documented

It must make sense

It must communicate what you intend to say

Include positive as well as negative changes in the patient’s condition.

Document non-compliance

Use hospital approved abbreviations

Document allergies

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ARISE Newsletter | August 2017

Document instructions given to the patient Addendum to the medical record should be clearly documented It must make sense It must communicate what you intend to say Make sure your documentation reflects the nursing process Chart the time you gave a medication, the administration route, and the patient's response Use objective data. If a patient refused his medications document exactly what occurred Include : Date, time, your title, and your full name with your signature in every entry.

Document how you provided care according to the standards of care outlined by the state and facility where you practice

Include nursing interventions. Add the interventions you provided and the patient’s response to the treatment

Include any patient refusals. If a patient refused treatment, document the incident.

Include the patient’s verbal and non-verbal response using as much objective detail as possible.

Include follow up care. Document how you followed up a medical situation with the appropriate patient care.

Make documentation a continuing, ongoing process. Do not leave large spaces of time in the patient’s chart.

ARISE Nursing Newsletter from University Hospital Sharjah

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ARISE Newsletter | August 2017

Documentation

DON'TS

Never use “liquid paper” or “white out”

Do not copy and paste previous documen-

tation

Do not criticize other medical profession-

als or personnel in medical record documentation

Do not omit information.

Do not use sticky notes in the medical

record

Do not change your style of writing

Do not skip lines or leave spaces between

entries

Do not write personal comments about a patient’s characteristics

Do not file a chart until it has been checked for completeness

Do not attempt to correct, clarify, add to, change or modify an entry in any way

Do not falsify records.

Do not use unrecognized abbreviations.

Do not guess or assume information.

Do not write what other people have heard, or think towards your patient.

Don’t make comparison when writing your

nursing assessment or evaluation

ARISE Nursing Newsletter from University Hospital Sharjah

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ARISE Newsletter | August 2017

Don’t Forget

UHS Medical Times 1

Newsletter | August 2017

UHS CERTIFIED AS A

MOTHER FRIENDLY WORKPLACE

To Check UHS Medical Times For August

University Hospital Sharjah in coordination with the Baby Friendly City Sharjah Campaign, has been designated as a Mother Friendly Workplace. This is the first step for University Hospital Sharjah in ensuring that mothers (employees and visitors) have access to a private, clean and safe area in which to feed their infants during their work duty and visiting time to the facility.

August Edition of UHS Medical times brings focus on Importance of Breastfeeding.

It includes initiatives taken by hospitals or organizations to encourage Breastfeeding.

University Hospital Sharjah is committed to the Baby Friendly City Sharjah Campaign and in conjunction with its designation as a Mother Friendly Workplace, our facility is working on its accreditation process for Baby Friendly Hospital Initiative (BFHI).

About 43% of infants 0–6 months old are exclusively breastfed. - WHO Over 800,000 children's lives could be saved every year among children under 5 years, if all children 0–23 months were optimally breastfed. - WHO

One in three babies in the UAE is exclusively breastfedat the age of 6 months. – UNICEF

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We Would Love to Hear

It also has precautions to be taken during Breastfeeding and guidelines for working moms to successfully breastfeed their children.

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ARISE Nursing Newsletter from University Hospital Sharjah

Call: +971 6 505 8555 or Mail: info@uhs.ae