विवरण
For high-quality, secure, and integrated healthcare service to take place, effective communication is essential. According to research, effective, cooperative communication improves patient outcomes most importantly by increasing treatment adherence, patient happiness, and practitioner job satisfaction. 2,3 Studies, on the other hand, show that poor communication results in unsatisfactory outcomes for both patients and providers. 79% of sentinel occurrences reported to the Joint Commission in 2015 included communication as a primary factor. Another major factor in complaints made to the Commission is ineffective communication. The complainant frequently expresses greater unhappiness with the relationship with the practitioner than with the treatment they received. Others reveal during the course of the investigation that a breakdown in communication among the medical staff played a role in the reported occurrence.
सारांश
- Family physicians provide continuous, comprehensive care to individuals and families, addressing physical, psychological, and social problems. They coordinate healthcare services with specialists and must document and communicate effectively.
- Family physicians are accessible for various illnesses and take responsibility for their patients. They detect early changes from normal and manage patients long-term within the family and community context.
- Medical documentation is the record of relevant patient data, while medical records contain history, care plans, treatments, diagnoses, investigations, and medications. Documentation is vital for safe, ethical, and effective patient care, providing a way to record, communicate, and ensure continuity.
- Documentation serves as a legal record, especially crucial in situations where things go wrong. Standard operating procedures (SOPs), principles, algorithms, notifications, handouts, and consent forms are also part of the documentation process.
- Communication involves giving information, expressing emotions, and building a two-way relationship to develop trust. Effective communication is essential for patients to feel better and comply with treatment plans.
- Efficient patient care involves communication, documentation, communication of documentation, and documentation of communication. This means telling patients, writing it down, and explaining what has been written, and writing down what has been told.
- Wagner's model of coordinated care emphasizes the importance of an informed and empowered patient and family, along with a prepared, proactive team. This requires coordinated care, proactive follow-up, patient education, collaborative decisions, and support from experts.
- Effective communication includes ensuring patients understand their problems, the importance of lifestyle management, and how to use their medications. It also involves providing tips for remembering medication timings, assessing self-management device usage, and addressing compliance issues.
- Proper medical records improve patient care, simplify data collection, ensure continuity of care, and reduce consultation time. They promote preventive care, enhance referral quality, increase efficiency, and aid in audits, ultimately leading to patient satisfaction.
- Good medical records also help in training, improvement, review meetings, research, and addressing medical-legal issues. Progress notes can be written using the SOAP acronym: Subjective (patient's statements), Objective (doctor's understanding), Assessment (diagnosis/impression), and Plan (next steps).
- Minimum requirements for good records include being well-structured, informative, organized, logical, consistent, simple, complete, accurate, and legible. They should contain basic patient information, problems, past history, and progress notes.
- Model prescriptions should include the doctor's name, qualifications, registration number, address, contact number, and prescription number. They should also include the date, patient's name, ID number, gender, age, weight, and other relevant identifiers.
- When prescribing, write the generic name if possible, use capital letters, avoid abbreviations, and prevent overwriting. Include the dose, route, frequency, strength, refill information, and details of continuing past medications. Also, include lifestyle advice and when to follow up, and refrain from prescribing medicines from other systems of medicine unless appropriately trained.
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