Explain two ways you can maintain documentation according to organisational requ

Question

Explain two ways you can maintain documentation according to organisational requirements?

How can you comply with an organisation’s reporting requirements?

Describe two different specialist services you may need to refer to, and how referral would be made

How could you identify changes in a person’s needs and behaviours and how should you report a change?

Why should you consult your supervisor when monitoring strategies to determine effectiveness? Provide two kinds of information they may be able to provide.

Explanation / Answer

1.The two ways where the documentation can be maintained would be digitally or analog way or maintain the organised record keeping system to ensure that medical records are easily retrievable.

2.Reporting requirement includes billing,analytical and post analytical data that have to be reported by the consultant or the physician.Responding to complaints,advocating for clients and seeking information,financial management,providing feed backs and mostly the accurate patient reports.

3.Specialist services that i need to refer is keeping a medical record standards and verbal reporting.For medical record standards ,establish an organised record keeping system to ensure that medical records are easily retrieved for review and available for use,store and maintain medical records in centralised and secured locationaccessible only to authorised personnels and provide equivalent security for electronic medical records.For verbal reporting,sometimes tha patient condition might be severe for any emergency operations while doctors will be waiting for the reports to receive according to the hospital standards,but verbal reporting system must be ensured in all the hospitals so that as soon as the test is done ,the result should be informed to the nurse or doctor clearly and verbally.

4.One of the most imporatnt services by the hospitals is ensuring care and providing them.Even if staff observes any change in patients behavious a special optimised plan should be developed and documented in such a away that it should be reported either to the doctor or to the nursing superintendent.The patients or the staff behavior should not be misjudged,observe for few days and then report to the higher authorities.

5.Monitoring iteslf is a form of evaluation or assessment for the positive outcome.It helps in decision makiing of any program or strategy by consulting the supervisors .Collect information and representing to the supervisors is helpful to promote transparency .

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