What are the characteristics of report writing?
Top 11 Characteristics of a Good Report
- Characteristic # 1. Simplicity:
- Characteristic # 2. Clarity:
- Characteristic # 3. Brevity:
- Characteristic # 4. Positivity:
- Characteristic # 5. Punctuation:
- Characteristic # 6. Approach:
- Characteristic # 7. Readability:
- Characteristic # 8. Accuracy:
When writing records what should you avoid using?
9 Things To Avoid When You Write A Report
- Play the lone ranger.
- Start with your credentials.
- Omit the executive summary.
- Focus on your tools.
- Write an encyclopaedia.
- Adopt a ‘one size fits all’ policy.
- Overload your report with jargon and buzz words.
- Gloss over detail.
What is the importance of medical records?
A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science.
What are the functions of medical records?
The primary functions of a medical records department include designing patient information, assisting hospital medical staff and creating informative statistical reports.
What are the purposes of documentation?
Although there are many explicit purposes for creating a scientific or technical document, there are four general categories: to provide information, to give instructions, to persuade the reader, and to enact (or prohibit) something.
Who owns patient medical records?
There are 21 states in which the law states that medical records are the property of the hospital or physician. The HIPAA Privacy Rule makes it very clear that, with few exceptions, patients should be given access to their records, in a timely matter, and at a reasonable cost.
What happens if there are documentation errors?
Incomplete documentation in patient clinical records can cause your organization legal and settlement fees, cause you to lose your license, contribute to inaccurate statistical databases, cause lost revenue/reimbursement, and result in poor patient care by other healthcare team members.
How do you prevent documentation errors?
Always write “discharge.” Avoid abbreviations that are non-medical, which can result in interpretation errors. Never accept questionable or incomprehensible orders. If you don’t understand the orders, or feel they are not in the best interest of the patient, question them every time.