The documentation of all processes and procedures in medicine plays an integral function. This is not only the coordination of all actions and plans but also an important aspect of quality control of services, reporting, and much more. In this regard, according to Documentation in Social Work: Evolving Ethical and Risk-Management Standards by Frederic G. Reamer, the very practice of reporting is periodically evolving, acquiring new principles, tools, and methods of application (2005). Over time, more innovative technologies have emerged that allow reporting in a form that is sometimes easier for social workers or other health care providers for use and maintenance.
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The proper circulation of the documents allows for to creation of a record of the employee’s actions and conveying orders, obligations, and performing a communication function. Moreover, the information used in the documentation must be clear, allowing conclusions to be drawn, avoiding discrediting, using modern language, and meeting other criteria for the intelligible storage of information (Reamer, 2005). The documentation can be used both at this stage of development and in the future. Therefore it is important that the documentation is written in accordance with the standards for creating and storing.
It is impossible to argue that any kind of reporting is an absolutely necessary document, the elimination of which is impossible without loss of the quality of the provided service and coordination of work. Without document circulation, not only the business but also the system of employees as a whole can cease to function. The working part of the workflow of the documentation is to fix the obligations and confirm their timely fulfillment. Moreover, there is a flow of information accumulated about organizations, people, jobs, roles, and their activities that without a system of documents, not only a company or industry itself would not function properly, but also the individual functions.
Over time, completely new standards and ways of maintaining documentation have appeared. For example, ethical considerations of the documentation of patient information have started to be applied. The social worker should be responsible for recording accurate information about the services provided and restricting access to the patient’s personal information. Patients themselves should be given access to information relevant to their situation. In addition, social workers can help with the interpretation of patient records if they think they can be understood in an unclear way (Reamer, 2005). Social workers perform the function of accompanying the study of such documents.
One example of situations where it is necessary to correctly protect information is family files when it becomes necessary to maintain a separate file for each family member due to the presence of disagreements in this group (Reamer, 2005). Thus, each family member can only be provided with information regarding his personal health situation. At the same time, access to files from other family members may be limited if this does not contradict the legislative decision on the ability to request information about another person.
In conclusion, healthcare records are used to store information about a patient’s medical history, planned treatment steps, diagnoses, and more. New standards are emerging for the use and storage of information, including patient personal data and ethical principles. An important role of social workers is to create correct and understandable documentation that can be used by patients themselves or other doctors. Documentation should be kept to standards in order to be clear and efficient to use.
Reamer, F. G. (2005). Documentation in social work: Evolving ethical and risk-management standards. Social work, 50(4), 325-334.
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