Ganser T
College of St. Scholastica, Duluth, MN, USA.
Top Health Inf Manage. 1997 Aug;18(1):32-7.
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.
随着长期护理行业适应重大变革时期，长期护理临床记录中的文档记录仍然面临诸多挑战。本文将探讨一些因针对参与医疗保险和医疗补助计划的长期护理机构进行的15年来首次重大联邦法规修订而对文档记录产生影响的因素。将简要介绍重塑长期护理临床记录核心内容的联邦监管环境，并讨论相关的法医学问题、信息技术问题以及影响长期护理的类似主题，以便更好地理解影响临床记录文档记录的多方面因素，从而认识到文档记录作为长期护理机构关键质量改进机会的重要性。
