Essay Available:
Pages:
1 page/≈275 words
Sources:
3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 4.32
Topic:
My State Board of Nursing NP Documentation Guidelines
Essay Instructions:
Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality safe care.
Discuss your State Board of Nursing nurse practitioner documentation guidelines and how this can impact your level of reimbursement in the clinical setting.
Essay Sample Content Preview:
Documentation Guidelines
[First Name, Last Name]
[Institutional Affiliation]
[Date]
Documentation Guidelines
My State Board of Nursing NP Documentation Guidelines emphasizes the presence or absence of documentation for seven elements as a definition of the level of Evaluation and Management (E/M) services provided. They include history, examination, medical decision-making, counseling, care coordination, nature of the problem presented, and time (DHHS, 2017). The first three are vital in determining the level of services, although the others are also essential for care coordination, counseling, and control. Additional four sub-elements also demonstrate a proper complexity level of services. They include “chief complaint (CC), history of present illness, review of systems (ROS), and past, family, and social history (PFSH)” (Bendix, 2014). Guidelines on documenting these four sub-elements direct health professionals on either including CC, ROS, and PFSH as separate elements of history or under a description of the same.
Additionally, the documentation guidelines also direct NP on the parties allowed to record and review the different elements. For example, the ancillary staff or the patient can fill a form to note ROS and PFSH. The NP is required to document all the medical issues they encounter when a patient visit the primary care setting (DHHS, 2017). These guidelines help external auditors to review the diagnoses a nurse practitioner is dealing with and influences medical decision-making. Throughout documentation for the seven elements, it is essential to note that information captured may differ for different patient populations such as children, pregnant wom...
Get the Whole Paper!
Not exactly what you need?
Do you need a custom essay? Order right now:
👀 Other Visitors are Viewing These APA Essay Samples:
- Inhibitors of 17β-hydroxysteroid dehydrogenase type 3 in the treatment of prostate canc. . .5 pages/≈1375 words | 10 Sources | APA | Health, Medicine, Nursing | Essay |
- Teaching Plan to Manage Type 2 Diabetes 4 pages/≈1100 words | 3 Sources | APA | Health, Medicine, Nursing | Essay |
- Can Public Health Laws and Ethical Principles Co-Exist?1 page/≈275 words | 2 Sources | APA | Health, Medicine, Nursing | Essay |
- MDI vs Nebulizer Treatment In Healthcare Facilities2 pages/≈550 words | 3 Sources | APA | Health, Medicine, Nursing | Essay |
- Nursing Assignment: Putting It All Together Project 6 pages/≈1650 words | 3 Sources | APA | Health, Medicine, Nursing | Essay |
- Pharmacotherapy for Gastrointestinal and Hepatobiliary Disorders1 page/≈275 words | 4 Sources | APA | Health, Medicine, Nursing | Essay |
- Understanding Risk Management within Medical Institutions3 pages/≈825 words | 3 Sources | APA | Health, Medicine, Nursing | Essay |