The Documentation In The Health Record Of Information Relate
The Documentation In The Health Record Of Information Relating To Pati
The documentation in the health record of information relating to patient rights and the patient’s understanding of those rights is required for healthcare decision making and use of the record in legal situations. The way this information is captured or documented must follow organization-wide policy. You are to compare and contrast the patient’s rights policy from Creighton University and UTMB, provide the analysis in the Module 01 Benchmarking Resources, and then select the information you recommend for your policy. Subsequently, you should write your policy on the documentation of information relating to patient rights. The completed policy should be approximately one page in length. If you reference a source for the policy, state the source at the end under a section titled "References."
Paper For Above instruction
The legal and ethical dimensions of patient rights documentation are vital components of healthcare records, underpinning both clinical decision-making and legal accountability. Developing a comprehensive policy on documenting patient rights ensures clarity, consistency, and compliance across healthcare organizations. This paper compares the patient rights policies of Creighton University and the University of Texas Medical Branch (UTMB), analyzes their similarities and differences, and recommends best practices to shape an effective documentation policy.
Comparison of Creighton University and UTMB Patient Rights Policies
Creighton University emphasizes the patient's autonomy, privacy, and informed consent as foundational principles within its patient rights policy. The policy underscores the importance of patients being informed about their care options, rights to confidentiality, and participation in decision-making processes. Creighton also highlights transparency regarding medical procedures, patient education, and the right to refuse treatment. Documentation practices derived from this policy focus on clear, detailed recording of patients' understanding, preferences, and consent, aligning with ethical standards and legal requirements (Creighton University, 2020).
Conversely, UTMB's policy emphasizes patient rights within a framework of organizational responsibilities and legal compliance. The policy delineates rights such as respectful treatment, confidentiality, and participation in care decisions, with specific attention to organizational obligations to uphold these rights. UTMB emphasizes the importance of documentation as a means to ensure accountability and legal defensibility. The documentation process includes recording discussions about patient rights, consents, and educational interventions, with an emphasis on accuracy, timeliness, and completeness (UTMB, 2021).
Contrasts and Similarities
Both policies prioritize patient autonomy, privacy, and informed decision-making, reflecting core ethical principles in healthcare. However, Creighton's policy adopts a more patient-centered approach focusing on individual understanding, while UTMB aligns documentation practices with organizational accountability and legal protections. Creighton emphasizes patient education and explicit consent documentation, whereas UTMB stresses detailed record-keeping to demonstrate compliance and protect against liability.
Recommendations for Policy Development
Based on the comparison, an effective documentation policy should incorporate the following elements:
1. Clear recording of patient rights explained during the care process.
2. Documentation of the patient's understanding and acknowledgment of these rights.
3. Recording of informed consents and refusals, including the specific information provided to the patient.
4. Documentation of any educational interventions provided to ensure patient comprehension.
5. Ensure documentation is accurate, signed (where applicable), and securely stored to facilitate legal and ethical accountability.
Proposed Policy on Documentation of Patient Rights
The organization shall document patient rights and the patient's understanding of these rights comprehensively within the health record. During each encounter, healthcare providers shall inform patients of their rights, including confidentiality, participation in care decisions, and the right to refuse treatment. The provider shall record the date, time, and nature of the discussion, the patient's expressed understanding, and any refusals or consents obtained. Documentation must be clear, concise, and objective, with signatures or initials of the provider confirming accuracy. Educational materials provided shall be noted, and any follow-up discussions or clarifications shall also be documented. All records shall be maintained securely to ensure confidentiality and compliance with legal standards.
References
Creighton University. (2020). Patient Rights Policy Manual. Retrieved from https://www.creighton.edu/patient-rights-policy
UTMB. (2021). Handbook of Operating Procedures – Patient Rights and Responsibilities. University of Texas Medical Branch. Retrieved from https://utmb.edu/policies/patient-rights-responsibilities