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Medical Record Documentation

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Introduction

For the Texas Board of Nursing, the first guideline necessary and required for the nurse practitioners is the necessity for keeping unique and as such, individual record for every patient (Texas Board of Nursing, 2017). On the other hand, one is required to establish an organized system for record-keeping as this ensures that the medical records will be easy to retrieve for reviewing as well as being available when the need is necessary, which include every stage like every point of the patient visit. Moreover, it is a necessity for storing and maintaining the medical records in a specifically centralized and secure location to make easy to access for the authorized personnel (Texas Board of Nursing, 2017). Another concern is keeping organized documents within the medical records by following a specific order. The identifiers of the members must appear in the entire document, dated, supporting the submitting codes, standard medical abbreviations to be used, patient encounters especially fax, telephone, as well as the electronic message exchanges (Texas Board of Nursing, 2017). It should also include problem lists or the medical conditions, the possible medications and as such, all the medical or health information necessary for the specific patient.

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As a practitioner, the guidelines can help in my reimbursement of the medical services. For instance, with the details of the patients, it will be easy to communicate (Bird, Zarum & Renzi, 2001). Besides, for allocation and assigning of bills, there are identifier numbers which will make it easy to retrieve the client information from the database (Ammenwerth & Spötl, 2009). Easy and efficiency in reimbursement is achieved at the expense of having an organized system (Brock, Casper, Green & Pedersen, 2006). Therefore, with a chronological order and a system for storing or documenting patient data or information, it will be much easier for in reimbursing care services like medication or drugs, care management plan and billing to the client (Kärkkäinen, Bondas & Eriksson, 2005).

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1. Ammenwerth, E., & Spötl, H. P. (2009). The time needed for clinical documentation versus direct patient care. Methods Inf Med, 48(1), 84-91.

2. Bird, S. B., Zarum, R. S., & Renzi, F. P. (2001). Emergency medicine resident patient care documentation using a hand‐held computerized device. Academic Emergency Medicine, 8(12), 1200-1203.

3. Brock, K. A., Casper, K. A., Green, T. R., & Pedersen, C. A. (2006). Documentation of patient care services in a community pharmacy setting. Journal of the American Pharmacists Association, 46(3), 378-384.

4. Kärkkäinen, O., Bondas, T., & Eriksson, K. (2005). Documentation of individualized patient care: a qualitative metasynthesis. Nursing ethics, 12(2), 123-132.

5. Texas Board of Nursing, (2017). Texas Medical Board-Board Rules: Texas Administrative Code, Title 22, Part 9. Retrieved from http://www.tmb.state.tx.us/idl/3E399486-3B51-843A-AAD2-E67B31810FB0

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