Introduction
It is worth noting that primary health care is the central link in the healthcare sector, and its main task is to improve the health of the country’s population. This type of care is the most demanded one due to the fact that, as a rule, it is provided by specialists in outpatient facilities. About 70-80% of patients begin and end examination and treatment at the primary health care level (Lakin et al., 2016). The purpose of this paper is to evaluate the importance of quality documentation and reporting in primary health care critically.
Discussion
It should be clarified that the work of specialists providing services in outpatient facilities is aimed at identifying the disease during a preventive medical examination or when a patient presents to the department seeking medical help (Basu et al., 2018). In addition, specialists carry out a number of preventive and medical procedures in order to prevent the development of complications of the disease, disability, or premature death. Thus, a very large percentage of patients with a wide variety of needs passes through such specialists, and the task of medical personnel is to document this as qualitatively as possible.
Also, specialists functioning in primary healthcare settings determine the indications and the amount of necessary diagnostic tests to determine the diagnosis. If the documentation is poorly maintained, this can lead to additional costs and resource overruns. Specialists need to specify the indications for hospitalization; they select patients who need high-tech types of treatment (Goodrich et al., 2018).
With poor-quality documentation and reporting, the possibility of medical errors increases at times, which affects not only patients but also providers (Kogan et al., 2019). In primary care settings, specialists conduct dynamic monitoring of patients with identified diseases and conduct treatment and rehabilitation in accordance with an individual plan of care and health-improving measures. In order for the activities to be systematic and care to be uninterrupted and carried out in a timely manner, each specialist should reflect all aspects of the services provided in the documentation.
Despite the fact that there are uniform reporting forms and documentation methods for all institutions, as well as for instructions for filling them out, statistics state that documentation is still not maintained on the required level of quality. Some of the standards of medical reporting are related to the management process and the use of data for planning health interventions and evaluating their implementation (Pitts et al., 2018). Also, reporting should be interlinked with the practical objectives of the healthcare organization. Documentation should show the progress in the treatment of the patient, cover up the shortcomings, and help identify ways to further develop or refine the course of treatment.
Statistical accounting and reporting are largely necessary for employees of a medical institution and its head in the first place (Thaker et al., 2016). It should be noted separately that medical statistical reports provide a summary of the volume and nature of services furnished by the institution and the conditions in which the institution operated during the reporting period. The analysis of these data helps to reveal the reasons for the negative performance of the institution as a whole and its primary care unit (Prater et al., 2019).
High-quality reporting characterizes the health of each patient, the volume and quality of medical care received by them, the resources of the institution that are used to provide them with care, and reflects the effectiveness of their use. Medical reporting is a pivotal part of primary care as it provides effective planning and regulation of the patient care process and allows concluding whether the measures taken by the health authorities are effective or not.
Further Points
It should be stressed that accurate documentation and reporting are the central aspects of effective communication between providers, clients, families, institution, and other agencies. Quality documentation contains all procedures, treatments, and client education delivered to a patient. Moreover, it tracks all responses to medical interventions so that the provider can adapt the course of treatment as required. Such documents are then shared with other healthcare specialists if needed and ensure the continuity of care. Moreover, when needed, such records provide valuable data for health-related research (Goldblatt et al., 2017).
Quality reporting implies documented complaints, family history, diagnosis, all procedures, and plan of care. Proper documentation and reporting should be confidential, exhaustive but succinct, accurate, and well-organized. In that case, given the sensitive nature of data it contains, it will not only be used as a source of information but will allow for a better quality of care.
Concluding Points
Thus, it can be concluded that quality documentation and reporting is one of the main aspects of high-quality primary care. Client records and other documents contain the entire patient history and plan of care; therefore, they need to be as accurate as possible. Despite the fact that there are specific universal criteria applied to all documentation and reporting in primary care, research suggests they are still not clean enough. For that reason, it is essential that all healthcare institutions continue training their employees to keep all documents and reports updated and as accurate as possible.
References
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