Healthcare Law | Essay | Doc

Running head: HEALTHCARE LAW
HEALTHCARE LAW
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HEALTHCARE LAW1
Introduction
There are various types of diseases and health conditions that are affecting the quality
of health service now (Park et al., 2017). This is more so due to the increasing complexity in
the variety of health condition, both mental and physical and when the need for an intricate
health care service that would address all the biomedical and the holistic parameter of the
care service delivered to the patient, in a very pertinent manner is considered – the
assessments and the therapeutic intervention delivered to the patients gets more complicated
and complex in many different ways (Zargaran et al., 2018). Moreover, nowadays, given the
quality of care delivered to a physically ill or a mentally ill patient is considered, each and
every step involved in a care process has to be taken into consideration in order to keep and
provide a legal as well as administrative safety both to the patient and the hospital workers
who were working or have worked in a certain clinical case. Multidisciplinary care or the
incorporation of multidisciplinary services is a very important parameter and it is to be
considered that while various clinicians from different medical and nursing and allied health
sciences disciplines has different roles to play in order to cure a case from all possible
therapies and interventions and in order to collaborate, the procedures of documentation must
be complied with, properly (Maxwell et al., 2017). Documentation can be done electronically
nowadays as the same has been made possible by the electronic health service solutions and
the usage and the proper application of the right form of electronic health care strategies has
not only improved the clinical documentation procedures but also eased the compliance rates
of the documentation procedures being attended by the health care specialists in a very
pertinent manner (Sermeus 2016). The various types of the health care institutions – starting
from primary care services to the specialty or tertiary level multispecialty hospitals in Canada
has helped the clinical procedures immensely with more clinical and legal safety and these
changes has been bought by the effective legislation and administrative policies, which are

HEALTHCARE LAW2
imperative to documentation which are done both electronically in the databases or non-
electronically, in the traditional manner. While various health care institutions and the health
care organizations in Canada finds it very difficult to adhere its employees with the write
nursing and medical documentation procedures, the other organizations performs fine in
helping their employees with the documentation procedure adherence process.
The documentation standards
There specific major legislative and professional association standards relating to
clinical record documentation in the organization, where I work as health care staff and it is
very important to all the employees who work here like me, follow the professional legal and
jurisdiction standards that pertains to the appropriate ways of documentation. As a nurse, the
entire assessment pertaining to client’s needs done as a nursing assessment are to be recorded
(Clifford et al., 2017). The clinically identified problems plus the clinical concerns that are to
be intervened or planned to be at least managed along with the main problem ( such as
comorbidities and associated conditions) are to be documented as well, according to the
legislation and standards (Jokstad, 2017). The assessment findings of a certain case along
with the nursing diagnosis made and the nursing care plan are formed based on which the
clinical intervention will be provided are to be documented as well. The clinical evaluation
with the ongoing medical and nursing management are to tallied with the right intervention
outcomes and are to documented as well (Kaposy et al., 2017). The information management
system must be used to store and document the clients’ objective and subjective type of
information, found during the nursing assessment are to be documented, according to the
standard. Other very important documentation that is carried out in the organization where I
work as a health care staff are - the time of clinical interventions and clinical assessments are
recorded in documents, the follow-up procedures and plan of the patient assessments are
documented as according to the legislation and the observations plus the clinical interventions