Explain the content and function of the various types of clinical documentation entered by health care providers.
Explain the content and function of the various types of clinical documentation entered by health care providers.
Skilled Nursing Facilities (SNFs) play a vital role in the care of our most vulnerable populations. Maintaining accurate medical records in the SNF setting is important for both quality of patient care, as well as compliance with regulatory bodies. For this week’s assignment, you will demonstrate your knowledge of medical record management in the SNF environment.
A local assisted living facility has decided to expand, with the addition of a skilled nursing facility adjacent to their current residential structure. You have been hired as a consultant to oversee the planning and implementation of medical records compliance. The facility owners and managers have a business background and are not familiar with the rules and restrictions that are applicable to SNFs.
Write a two-page executive summary for the owners and managers, including the following information:
Regulatory bodies and their roles (bullet points are acceptable)
Primary payers, and their payment models (bullet points are acceptable)
How patient records should be maintained (i.e. paper, electronic, what technologies and equipment will be needed).
What information must be included in the record for every patient.
Liability issues to be aware of, and how to avoid them.
Please ensure your content speaks to the target audience.
APA requirements: Title and reference pages, three sources.
Answer preview to Explain the content and function of the various types of clinical documentation entered by health care providers.
APA
751 words