Biomaterial Database

Quality variables for documentation in long-term care. 1997

T Ganser

College of St. Scholastica, Duluth, MN, USA.

Documentation in long-term care clinical records continues to pose many challenges as the industry adjusts to a period of significant change. This article will look at some of the forces impacting documentation resulting from the first major federal rewrite in 15 years for long-term care facilities participating in Medicare and Medicaid. A short synopsis of the federal regulatory environment that reshaped the core content of the long-term care clinical record will be presented, as well as a discussion of related medicolegal issues, information technology issues, and similar topics affecting long-term care will have a better understanding of the multifaceted forces impacting documentation in the clinical record and thus recognize the importance of documentation as a key quality improvement opportunity for long-term care facilities.

UI	MeSH Term	Description	Entries
D008134	Long-Term Care	Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care.	Care, Long-Term,Long Term Care
D008499	Medical Records	Recording of pertinent information concerning patient's illness or illnesses.	Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D011785	Quality Assurance, Health Care	Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.	Quality Assessment, Health Care,Health Care Quality Assessment,Health Care Quality Assurance,Healthcare Quality Assessment,Healthcare Quality Assurance,Quality Assessment, Healthcare,Quality Assurance, Healthcare,Assessment, Healthcare Quality,Assessments, Healthcare Quality,Assurance, Healthcare Quality,Assurances, Healthcare Quality,Healthcare Quality Assessments,Healthcare Quality Assurances,Quality Assessments, Healthcare,Quality Assurances, Healthcare
D004282	Documentation	Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information.	Documentations
D006707	Homes for the Aged	Geriatric long-term care facilities which provide supervision and assistance in activities of daily living with medical and nursing services when required.	Old Age Homes,Residential Aged Care Facility,Senior Housing,Home, Old Age,Homes, Old Age,Housing, Senior,Old Age Home
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000368	Aged	A person 65 years of age or older. For a person older than 79 years, AGED, 80 AND OVER is available.	Elderly
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D014487	Centers for Medicare and Medicaid Services, U.S.	A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.	Centers for Medicare and Medicaid Services,United States Centers for Medicare and Medicaid Services,United States Health Care Financing Administration,Centers for Medicare and Medicaid Services (U.S.),HCFA,Health Care Financing Administration,Health Care Financing Administration (U.S.),Health Care Financing Administration, U.S.
D019451	Information Management	Management of the acquisition, organization, storage, retrieval, and dissemination of information. (From Thesaurus of ERIC Descriptors, 1994)	Management, Information