For all hospitals and clinics, their primary function is the wellbeing of their patients. The hospital and its medical staff must be able to deliver medical service to their patients as governed by the laws of the land and codes of ethics of the medical profession. Adherence to laws and codes helps to protect both the hospital and its medical personnel.
The documentation of all the activities that concern their patients directly or indirectly helps to achieve protection for all the parties involved. Incomplete or lack of documentation of patients can lead to significant liability for both the hospital and its personnel.
Therefore, healthcare centers ensure that the right documents are filled at every step of the care that is given to patients. As such, several documents are used while treating a patient. Amongst the numerous documentations, some are frequently used. In no particular order, the top-10 most recurring documents in the healthcare system are stated below.
- Patient Information Document
- Responsibilities and Rights Document
- Patient Instructions Document
- Patient Progress and Questionnaires Documents
- Missed Appointment Document
- Waiver Document for Financial Responsibility
- Informed Assent and Consent Document
- Patient Complaint Document
- Patient Discharge Document
- Patient Chart
Patient Information Document
This document is amongst the vital document that is used in almost every healthcare center. It helps to collect all the essential information of a patient, which includes demographic data and other beneficial information. In recent years, the patient information document is mostly presented in an electronic form. However, there are still practices that use paper forms. Usually, the reception or the front desk of the healthcare center provides the patient information document to patients before an appointment or before a medical procedure.
Responsibilities and Rights Document
The responsibilities and rights document is a small document, which consists of all the responsibilities and rights of a patient in healthcare. In most cases, this document is presented to a patient upon admission or the first visit to a healthcare center. A patient is expected to read and sign the document at the reception of a center.
Patient Instructions Document
At each step of care, a patient requires a set of instructions to follow. In cases of surgical procedures, a patient is usually given a detail instruction of pre-surgery and post-surgery guidelines to follow. This type of detailed documentation is also used in situations such as psychotherapy and physiotherapy to aid with patient recovery.
Patient Progress and Questionnaires Documents
This type of document helps to gather information regarding the state of health or the progress of the recovery of a patient. Generally, such a document would have a set of questions and answers that are tailored to provide information in the form that categorizes patients into groups for ease of management.
Missed Appointment Document
To reduce the likelihood of a patient missing his/her appointment, a lot of hospitals and clinics have a policy that penalizes patients when they miss their appointment. This penalty usually comes in the form of extra charges. However, it is mandatory that patients are aware of the policy by providing them with a document that spells out the implications of a missed appointment.
Waiver Document for Financial Responsibility
In most countries, patients are required by law to have some form of health insurance. In the event of a patient that is without insurance or the insurance does not cover a specific treatment/procedure, the waiver document for financial responsibility allows the healthcare center the power to collect money directly from the patient.
Informed Assent and Consent Document
All patients have the freedom to consent or refuse treatment. In some instances, it is required that patients consent to certain types of treatments, which include surgery and immunization. Also, in cases of emergency, patients may opt to sign DNR (do not resuscitate), which prevents healthcare personnel from reviving them.
Patient Complaint Document
This document is a simple document that allows the patient to lodge complaints. It is usually issued to patients after the provision of a health service.
Healthcare Power of Attorney
This document allows a third party to make critical decisions when a patient is in a state, which does not allow them to make rational or conscious decisions. This document is essential as it allows for decision making in cases of emergencies.
The patient chart is a vital document that provides the entire medical history of a patient, which may include diagnoses, treatments, medications, allergies, immunization records, to name a few. This document helps healthcare providers deliver high-quality care to their patients.