Health Documentation Essay Example Paper
Running head: HEALTH DOCUMENTATION HEALTH DOCUMENTATION Student’s Name Institution Affiliation Course Name Instructor’s Name Date 1 HEALTH DOCUMENTATION 2 Health Documentation HIM is the practice of acquiring, analyzing, and protecting digital and traditional medical details vital in offering quality patient care. The HI professionals are responsible for handling these critical documents to ensure easy documentation and retrieval to enhance smooth operations for all patients who visit the facility Health Documentation Essay Example Paper.
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The documents include but are not limited to Progress notes, History and physical, Operative report, and Discharge Summary. Progress Note This is the part of the medical record in which the health professionals record details to track the patient’s clinical status and improvements for the whole period of hospitalization or even throughout outpatient care. The purpose of this note is to provide a daily account of the patient’s status to reveal whether the patient’s health status is deteriorating, improving, or just stagnated. A progress note is used to communicate findings, opinions, and plans among the medical team to better the patient (Myklebust & Bjørkly, 2019) Health Documentation Essay Example Paper