What is physician documentation?

Dental clinical documentation

The course is aimed at information management professionals and health sciences professionals who need to know the Clinical Documentation and Admission Services (SADC) and the areas of activity of medical documentalists in the organizational structure of health institutions.

The pedagogical coordinator is the reference person for participants throughout the course for all non-academic issues. Participants may contact him/her at any time, either by e-mail or by telephone. In case the telephone is not active, they can leave their messages on the voicemail.

In order to solve any technical problem that may arise, the student should contact the Course Coordinator by the most convenient means (see section “Pedagogical Team”).

The course has more than met the expectations I had before it started. Excellent preparation and dedication of the teacher, a 10. A quality methodology, and a wide and varied range of content. Dynamic, entertaining and profitable course.

What are clinical documents?

A set of medico-legal documents containing the necessary information for the correct care of patients and includes information of a healthcare, preventive and social nature.

What is health documentation?

Health documentation is a methodology that favors the construction of knowledge, and its objective is the search for valid and reliable information through a process that involves time, reading, writing and technology.

What is non-clinical documentation?

NON-CLINICAL DOCUMENTATION Non-clinical documentation is the set of administrative documents necessary for the management, organization and coordination of health center resources. Together with clinical documentation, it constitutes the healthcare documentation.

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Mention some of the clinical documentation.

The clinical history originates with the first episode of illness or health check-up in which the patient is seen, either in the hospital or primary care center, or in a physician’s office. The clinical history is included within the field of clinical semiology.

In addition to the clinical data related to the patient’s current situation, it includes data on personal and family history, habits and everything related to the patient’s biopsychosocial health. It also includes the evolutionary process, treatment and recovery. The clinical history is not limited to being a simple narration or statement of facts, but includes in a separate section judgments, documents, procedures, information and informed consent. The patient’s informed consent, which originates from the principle of autonomy, is a document in which the patient records and signs his acknowledgement and acceptance of his health situation and/or disease and participates in the health professional’s decision making.

What are the clinical data of a patient?

These refer to: presence of family history of interest (FA), presence of personal history of interest (PA), drug allergies (MA) and updated list of health problems (LP).

What is Minsa health documentation?

It is any document approved by the Ministry of Health that has the purpose of transmitting standardized and approved information on technical aspects, whether they are assistance, sanitary and/or administrative, related to the scope of the Health Sector, in compliance with its objectives; as well as to facilitate the adequate …

Why is health documentation important?

In short, the objective of this document is to obtain as much information as possible about the patient’s state of health and personal, family and work relationships, as well as habits and customs, which will be useful for the treatment of the disease.

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Medical History

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How many types of health documentation are there?

This information can be divided into two types: clinical documentation, which is related to the patient’s health; and non-clinical documentation, which is necessary for care, but is not related to health information.

What is the clinical admissions and documentation service?

The Admission and Clinical Documentation Service (SADC) is a non-care service responsible for facilitating the user’s access to specialized health care on an outpatient or inpatient basis, as well as for managing the clinical history. The Admission Service is multidisciplinary in nature.

How long does a medical record have to be kept?

Thus, the medical record must be kept for a minimum of five years from the date of discharge from each health care process.

Health documentation pdf

Every patient has the right to have the entire care process documented. This entails the obligation for healthcare professionals to record, in writing or on a suitable technical support, all information that may be of importance to the patient’s state of health, and this information must be included in the medical record.

In addition, there is the right to obtain certain documentation related to the care process or the state of health, such as the clinical discharge reports at the end of a care process or the certification of the patient’s state of health.

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Health centers and individual physicians will only provide access to the medical records of deceased patients to persons related to them, for family or de facto reasons, unless the deceased has expressly forbidden it and this has been accredited. In any case, access by a third party to the clinical history due to a risk to his/her health will be limited to the pertinent data. Information that affects the privacy of the deceased or the subjective notes of the professionals, or that harms third parties, shall not be provided.