The Documentation Related To Surgery And Discuss The Legal And Professional Requirements – Essay Example
The paper "The Documentation Related To Surgery And Discuss The Legal And Professional Requirements" is an exceptional example of an essay on nursing. Documentation related to surgery is concerned with raising standards of making surgical procedures safer and more successful. Documentation related to surgery is necessary when an element of performance in surgery requires a written procedure. Documentation is also required when an element of performance in surgery requires medication labels, performance improvement reports, data, evidence of testing, a license, a written plan, and a policy. There are legal and professional requirements associated with confidentiality and record keeping in relation to surgery. Medical records are important in determining the correct course of health care because they allow a physician to keep track of a patient’s medical history. There are legal and professional requirements that outline their collection, use, and storage, as well as disclosure of personal health information of patients. It is the legal and professional responsibility of physicians to meet these requirements. Federal statutes protect patient confidentiality. Physicians are legally and professionally obliged to keep patients’ medical and personal information and records private and confidential (Carpenter et al 2007, p. 328). In case medical and personal information about patients is to be released by physicians, written consent from the patients must be provided. Patients may restrict physicians from disclosing information about their condition to family members or friends. In such cases, the physicians must also seek express consent from the patients. In law, a physician may be required to disclose a patient’s health information in a variety of circumstances without the patient’s consent. Such circumstances include monitoring of claims for payment when writing mandatory reports when giving reports under the Workplace Safety and Insurance Act, and when responding to court orders, subpoenas, and summonses (Mann & Williams 2003, p. 330).