were are administrative documents like the living will placed in a patients medical record?
I have researched this question and can not find the answer. Where in the patients medical records would u place documents like the living will, health care proxy, DNR order, Power of attornet and other legal documentation?
I would only place copies of these documents in the medical record, the patient, his attorney, or family should maintain the original copies. After all, any patient has several medical records (hospital, each doctor provider), why would anyone put the original in any one record. DNR orders are usually hosptial stay specific, but think: what if the person is at home after the hospital stay, and "dies" at home? Paramedics arrive. Any DNR ought to be maintained by the legal family representative, not by some hospital the patient was in some time ago.
So for medical records, copies only, originals to be maintained outside the medical record. I can see some hospital administrators flinch at my suggestion.
The original of the power of attorney is kept with a solicitor. A certified copy would be with any medical records, although usually a summary sheet contains contact details for who has power of attorney rather than the file containing the document.
A variation on the living will is a tattoo of DNR on the chest of the patient.
I mean were in the record are they placed? adimn. area or clinical or what?
hello i am in need of help i see someone else have ask the question but no answer: will i have the same issue my assignment is for the nurse midwife's proctorship form, list the procedures that will be reviewed by using privilege specific to the nurse midwife, which can be find on CNM's web site and in addition to the privilege include items that are specific to the JC's six competency
my teacher said the form should have benchmark numbers, triggers, procedures that are going to be monitored. i just need someone to help me get it started and i will finish it i am really having a hard time with this i do not want anyone to do the whole assignment just help get me started i have been working on this for four days and still do not get it.
Administrative documents like a living will, health care proxy, DNR order, power of attorney, and other legal documentation are typically placed in a patient's medical record in a specific section called the "Legal/Ethical Documents" section. This section is specifically designated for storing and organizing important legal and administrative documents.
Here is a step-by-step guide on how to find and place such documents in a patient's medical record:
1. Identify the patient's medical record: Begin by locating the patient's medical record. This can typically be done by accessing the hospital's electronic health record system or by requesting the physical file from the medical records department.
2. Access the appropriate section: Once you have the medical record, navigate to the "Legal/Ethical Documents" section. This section may vary depending on the specific electronic health record system being used, but it is commonly found under a "Documents" or "Administrative" tab.
3. Determine the type of document: Identify the specific administrative document you need to place in the patient's record, such as a living will, health care proxy, DNR order, or power of attorney.
4. Scan/upload the document: If the document is in physical form, scan it using a document scanner or a multifunction printer. Ensure that the scan is clear and legible. If the document is already in electronic form (e.g., emailed as a PDF file), simply upload it to the electronic health record system.
5. Organize and label the document: Once the document is in digital format, rename it appropriately for easy identification. It is often helpful to include the patient's name and the type of document in the file name (e.g., "JohnDoe_LivingWill.pdf"). If the system allows for it, you can also add relevant metadata, such as the date of the document or any associated notes.
6. Upload the document to the appropriate section: Upload the scanned or electronic document to the "Legal/Ethical Documents" section. If required fields are available, fill them out accurately to provide additional context or details about the document.
7. Verify and document the upload: Double-check that the document has been successfully uploaded and stored in the patient's medical record. If there is a specific protocol for documenting the inclusion of administrative documents, ensure that it is followed correctly.
By following these steps, you should be able to find the appropriate location within a patient's medical record to place administrative documents like a living will, health care proxy, DNR order, power of attorney, and other legal documentation.