4.1 Documentation Estimated reading: 2 minutes 35 views Authors The hospital should define the scope of documentation for quality-related services in procedural instructions. The aim is to regulate how organization and patient-related information can be stored, forwarded and retrieved. The presentation of the information in forms, their recording, possibly also via EDP, their forwarding and archiving must be clarified. Storage must be secured for the specified period. It must be possible to access the medical records within a reasonable period of time. The completeness of the medical records must be verifiable. The need for documentation must be clarified for each medical procedure with regard to traceability of measures, reporting in the workflow or economic purposes. When documenting, care must be taken to ensure that the recorded data can be transmitted quickly and without loss of information. The documentation serves the flow of information and must not impede it. The data should be collected and archived in such a way that it can be evaluated at a later date, including for comparison with other service providers. The statutory and professional regulations (Social Security Code, Professional Code, Federal Collective Agreement, agreements on outpatient surgery, Narcotics Ordinance, Pharmacy Ordinance, Infection Protection Act, X-ray and Radiation Protection Ordinance, etc.) must be complied with. The statutory retention periods must be complied with. Proof of compliance with environmental protection obligations should be provided. The QM system should be documented in a quality management manual with a quality assurance plan, procedural instructions, method descriptions (care standards, work instructions, treatment patterns). The manual may contain further directories (inventory of equipment, organization chart with function descriptions, procedure list, recognized rules, validation documents). Procedural instruction4.1.01 Steering Records 4.1.02 Signature list Hand signal 4.1.03 Data protection 4.1.04 EDP 4.1.05 IT data backup 4.1.06 Collection of data for external QA according to § 137 SGB V 4.1.07 Patient identification via barcode 4.1.08 Patient file 4.1.09 Care documentation 4.1.10 Care service documentation 4.1.11 OP report 4.1.12 Patient-related reports, doctor's letter 4.1.13 Classification systems 4.1.14 Participation in registers 4.1.15 Tumor documentation 4.1.16 Use of patient samples and tissues 4.1.17 Acceptance of documents (incoming mail) 4.1.18 Archive for medical records 4.1.19 Release of medical records 4.1.20 Digital archiving, microfilming 4.1.21 Destruction of medical records 4.1.22 Administration registry 4.1.23 Document management 4.1.24 Coding ICD, OPS, DRG 4.1.25 Inpatient billing 4.1.26 Outpatient billing 4.1.27 Ambulance card 4.1.28 Registry in the outpatient clinic 4.1.29 Coroner's inquest and death certificate 4.1.30 Photo documentation 4.1.31 Wound documentation 4.1.32 Partogram (Docu Birth) 4.1.33 Formularium 4.1.34 Tracing of implants 4.1.35 Batch documentation of blood products 4.1.36 Glossary and abbreviations Next - 4 Information system 4.2 Communication and marketing
