Concept on Mobile Physician Documentation

Running head: MOBILE PHYSICIAN DOCUMENTATION
Concept Development of Mobile
Documentation for Physician in Hospitals
Name of the Student
Name of the University

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MOBILE PHYSICIAN DOCUMENTATION
Table of Contents
Introduction......................................................................................................................................2
1. Assessing the Current Physician Documentation in Hospitals....................................................2
1.a) Responsible Person for Documentation in Hospital (Who Documents?)............................2
1. b) Various Process of Documentation (How Documents?).....................................................3
1.c) The Time of Documentation (When Documents)................................................................5
2. Assessing the Possibilities of Optimization by using Mobile Documentation for Physician in
Hospitals..........................................................................................................................................6
2.1 Current Situation and Process:...............................................................................................6
2.2 Identification of Modifications:.............................................................................................6
2.3 Modification:.........................................................................................................................8
3. Concept of Mobile Documentation for Physicians in Hospitals...............................................11
3.1 First Visit:............................................................................................................................11
3.2 Second or Further Visit:.......................................................................................................12
3.3 Documentation and Data Transfer:......................................................................................13
3.4 Security Implementation:.....................................................................................................14
Conclusion.....................................................................................................................................16
Bibliography..................................................................................................................................17

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MOBILE PHYSICIAN DOCUMENTATION

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Introduction
This study aims to provide information about the needs and important of mobile
documentation for Physician in hospitals. It has been observed that physician in hospitals are
spending more time in preparing documentation rather than take direct care of the patients.
Therefore, this study provides the outline of current documentation process of hospitals by
physician and the possibilities of assessing mobile documentation in their process along with the
develop concept and security issues.
1. Assessing the Current Physician Documentation in Hospitals
Documentation of medical record is an important requirement of every hospital. It is
required for the purpose of recording pertinent facts, observations and findings about a patient’s
health history (Blair & Smith, 2012). It documents the details of the present and past illnesses,
treatments and tests of the patients. Health documents play a significant role in contributing to
the quality of patient care that is carried out in the hospitals.
1.a) Responsible Person for Documentation in Hospital (Who Documents?)
The physicians are responsible for documenting the medical history of the patients that
will contain evidences of the physical examinations (Calloway, Akilo & Bierman, 2013).
Physicians spend most of their time in documenting about the diagnosis, treatments, procedures
and investigations for every treatment that is carried out (Timimi, 2012). The physicians are also
responsible for documenting the medical management plan of the hospital. Copies of certificates
that are provided to the patients are also documented by the physicians.

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1. b) Various Process of Documentation (How Documents?)
In the hospitals, there are several types of documentation that taken place. These are the
followings -
A) Medical Record: This record consists of the patient details along with diagnosis
details. It contains the result of treatments so that it facilitates future care of the patients. The
medical practitioner is responsible for maintaining the medical records of the patients and for
regular updates so that appropriate care of the patients can be carried out in the hospital
(Devkaran &O'Farrell, 2014). This record is documented from the time when the patient is
admitted to the hospital till the time of discharge. It is updated on a regular basis by the
physicians and medical practitioners (Haux et al., 2013). The medical record is generally
documented manually by the physicians present in the hospital.
B) Physical Examinations and History Record: It is the responsibility of the physicians
or Allied Health Professionals to perform physical examinations and admission history of the
patients (Swartz, 2014). This H&P record must be completely updated before any surgery or
other invasive procedures. It contains information about the present illness, past medical details,
physical examinations and its results. It also contains the action plan that needs to be carried out
for carrying out the treatment of the patients. Documentation procedure is carried out manually
in the hospitals.
Consider a situation when complete history of the patient is not documented before the
surgery. In this case, the surgeon needs to first complete the documentation procedure before
carrying out the operation. Invasive procedures like OR procedures, endoscopies, tubal ligations
and ambulatory surgeries must include H&P record (Williams et al., 2014). Attending medical

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staffs and physicians are mainly responsible for documentation of H&P. It needs to be updated
on a regular basis by the physicians (Johnson et al., 2014). Dentists are responsible for their
patient’s H&P that is related to dentistry. In case of ambulatory surgical patients, this document
must contain list of the current medications and other essential information of the patients.
C) Report of the Emergency Department: This report contains time of arrival of the
patient, clinical observations, results of treatment, and patient’s condition at the time of
discharge, and history regarding the illness along with its physical findings (Taubman et al.,
2014). It will also consist of the details of final disposition, instructions for the purpose of
follow-up care and treatments. The medical practitioners and physicians who are handling the
emergency departments are responsible for carrying out this documentation procedure. The
physicians make sure that this emergency record is accurate so that they can analyze this case in
the future and further help the patients to recover in an effective manner (Ward et al., 2014). This
record is maintained in a file and the information is recorded manually.
D)Progress Report: This document will contain the progress report of the patients.
Handwritten notes are used by most of the hospitals for recording the daily health progress of the
patients. It will help to provide the health record of the patients in a chronological order. It will
help to provide details about the change in the health condition of the patients.
E) Operative Report: This type of report is documented after the completion of an
operative or high risk procedure before transferring the patient to the next level of treatment and
care (Mamykina et al., 2012). Operative reports are prepared and documented by the surgeons
who carry out the operations and high risk procedures.