Understanding Healthcare Documentation: Types and Importance
Understanding Healthcare Documentation
Document: Information recorded on a support, explaining information and average records (paper, digital format).
Importance of Documentation
Documentation is crucial for quality care, providing rapid access to information and enabling appropriate and effective care. Documents are legally required and necessary to justify actions and results in case of claims or legal problems. Therefore, it is essential to properly preserve important documents.
Structure of a Document
- Header: Located in the top left corner, it contains data identifying the sender. The upper right corner usually identifies the recipient.
- Body: Reflects the specific content information of each document.
- Footer: Includes the date (location and date written) and the signature of the person who prepared the document.
Types of Documentation
- General Documentation: Similar to documents used in any other organization or job, such as invoices.
- Health Information: The set of documents generated in patient care and administrative activities related to this care.
- Clinical Documentation: Directly related to patient care.
- Non-Clinical Documentation: Generated in the activities of management and administration related to patient care. An example is the application of material.
Documentation in Private Consultations
In private consultations, administrative and management functions are met. Management tasks typically performed by the assistant and involving the use of documents include communicating with patients and providers, managing patient appointments, shopping, and budgets.
Communication with Suppliers and Customers: Business Letters
Communication can be verbal (in person or by telephone) or electronic (SMS, emails, etc.).
Business Letter Components
- Heading: Details of the sender (company or personal) and data of the recipient.
- Content or Body of the Letter:
- Greeting: Formal courtesy greeting. Established formulas in regular use (Sir, Madam).
- Text: Respectful, short, natural, with short sentences, simple and clear.
- Farewell: Formal and polite, e.g., “Sincerely.”
- Caption: Signature: Name of the person signing.
- Date: Place and date.
- Appendix: Any attached documents. Example: budget.
Calendar Appointments at Health Consultation
The agenda includes patient name and surname, Payment, Phone Number, Other information, visit Reason, and Duration.
Non-Clinical Documentation
These are documents used in health centers in the management and administration activities related to attending to patients.
Purpose
To leave a written record of administrative actions and characterize these acts so they can be conducted in an orderly manner and without failures.
Examples
- Request and receipt of material: To apply the products used in healthcare.
- Document for sending material to the sterilization service: A list of the material is attached (inventory).
- Asking and receiving medications: A unit dose system is currently used, where each unit takes care of the individual petition for prescribed daily medication to the patient.
- Full planning diets: To report to the kitchen the diets of patients. Comparing the document request (command) and receipt (bill), it is apparent that the requested material has been received.
Health Cards
Used to organize health services. Personal identification of citizens for healthcare provided by the NHS. The healthcare administration issues the card. Includes surnames and names of the cardholder, and personal identification of the owner, valid throughout the territory.