Document keeping in the healthcare system is crucial as it reflects the patient’s journey in treatment and provides feedback on future measures. In particular, the charting service should correctly present the patient’s medical history, test results, treatment, and outcomes to provide the best care.
Specifically, addiction treatment requires accurate record-keeping to ascertain the treatment’s extent and show the patient’s response throughout the treatment process. According to Mallard Lake Detox, the following are qualities of the best charting service for addiction treatment.
Educated and Trained Healthcare Providers
Health care providers must be given thorough training in the technical elements of documentation, in all contexts, and at all service levels. They should also recognize the policies and procedures relevant to documentation of addiction treatment.
The time necessary for documenting must be taken into account so that each nurse can do the following:
- Skillful and functional use the healthcare documentation system
- Have the ability and knowledge regarding computer use and all the associated hardware.
- Be capable of professionally using the documentation software systems to present relevant healthcare reports.
Follow The Correct Policies And Procedures
The healthcare provider must be familiar with, and apply to, all documentation-related organizational policies and procedures. These rules or guidelines for ensuring efficiency through the “downtime” documentation system are of particular significance when the EHR addiction treatment available does not work.
Use Standardized Terminologies
With standardized terminology, healthcare providers will easily add and analyze data. These terminologies should include the words used to define patient and client care preparation and assessment in various settings.
Offer Ultimate Data Security
As required by organizational policies and procedures, accrediting agencies, industry standards, government mandates, accrediting agencies, and administrative policies and procedures, protection mechanisms must be developed and incorporated into documentation systems, on paper or electronic to ensure that the following is accessible,
- Data Security
- Patient identity security,
- Patient information confidentiality
- Information confidentiality for health practitioners
- Organizational information confidentiality
Correct Record Entries
Data entry is a significant aspect of charting service as it determines what is to be reflected in the results. Therefore the healthcare providers involved in treating the addicted patient should clearly understand its importance and observe keenness when entering information.
It is also advisable for healthcare providers to scrutinize every data they enter to ensure that it reflects the correct service. Notably, every entry in organization’s EHR addiction treatment should:
- Show the correct date, time, and stamp of the healthcare provider who entered it.
- Use the standard terminology, including symbols and acronyms.
- Legible to all the parties that might use it.
- Valid, accurate, and complete
- Authenticated to confirm that nothing has been altered and that the information is truthful.
Notable Documentation Characteristics
Documents of high quality are:
- Precise, appropriate and uniform
- Full, clear, and succinct
- Contemporary, sequential and timely
- Showcase the Nursing phase reflectivity
- Legible in particular, concerning the resolution and related qualities of EHR material shown on different computer screens
- Permanently retrievable in a nursing manner
Addiction treatment requires a high-quality charting service for the best results. Besides, quality documentation will provide the effectiveness of various interventions taken and the progress in patient’s rehabilitation.