The purpose of this guideline is to explain to healthcare professionals and administrative employees what their records management obligations are in terms of the National Archives and Records Servi...ce of South Africa
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2nd edition. There have been many requests over the past few years for advice about what information should be included in a patient record for leprosy. The patient record should contain the essenti...al information for the clinical management of the patients, for monitoring adherence to MDT, and for reporting to the national programmes and to WHO. Patient records vary between countries due to differences in health systems and are modified from time to time. The Model Patient Record is recommended as a reference and as a check list when evaluating programmes and when reviewing existing patient records.
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The Protection of Personal Information (POPI) Act
Confidentiality: providing and protecting information
• Health care practitioners hold information about patients that is private and sensitive.
• The National Health Act (Act No. 61 of 2003) provides that this information must not be given to... others, unless the patient consents or the health care practitioner can justify the disclosure.
• Practitioners are responsible for ensuring that clerks, receptionists and other staff respect confidentiality in their performance of their duties.
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Consistent, current and complete documentation in the medical record is an essential component of quality patient care. The following 21 elements reflect a set of commonly accepted standards for medical record documentation. An organization may use ...these elements to develop standards for medical record documentation. NCQA considers 6 of the 21 elements as core components to medical record documentation. Core elements are indicated by an asterisk (*).
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This guide can be used to train nurses in the field to succeed in their role in the hypertension program. It teaches how to screen patients correctly, register and follow-up with patients, retrieve defaulters, record patient visits, and to report da...ta.
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Patient Safety Checklist
This checklist will help you write down information your doctor and nurse may need.
3rd edition. Patient safety standards are critical for the establishment and assessment of patient safety programmes within hospitals. This third edition of the ...edbox">Patient safety assessment manual provides an updated set of standards and assessment criteria that reflect current best practice and WHO guidance. The manual will support the implementation of patient safety assessments and improvement programmes within hospitals as part of the Patient Safety Friendly Hospital Framework to ensure that patient safety is prioritized and facilities and staff implement best practices. The manual is a key tool for use by professional associations regulatory accrediting or oversight bodies and ministries of health to improve patient safety.
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Technical Series on Safer Primary Care
This handbook builds on lessons learned from surveys implemented 2015-2017 and advice provided by the Global task force on TB patient cost surveys. It provides a standardized methodology for conducting health facility-based cross-sectional surveys t...o assess the direct and indirect costs incurred by TB patients and their households. In addition, it provides recommendations on results dissemination, engaging across sectors in policy dialogue and enabling action and related research for effective modifications in care delivery models, in patient support, and wider cross-sectoral interventions.
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Technical Brief
HIV patient monitoring and case surveillance
WHO/HIV/2017.14
Against this background of nearly 20 years of experience of research, development and
improvement in patient safety, the role of incident and adverse event reporting, as well as the
benefits that derive from it, is still a work in progress.This do...cument has two main purposes:
• to provide an up-to-date perspective on patient safety incident reporting and
learning systems currently in place, including how to fill in existing gaps in these
systems;
• to provide practical guidance on the establishment and effective use of patient
safety incident reporting and learning systems.
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Patient safety standards are critical for the establishment and assessment of patient safety programmes within hospitals. This third edition of the Patien...t safety assessment manual provides an updated set of standards and assessment criteria that reflect current best practice and WHO guidance. The manual will support the implementation of patient safety assessments and improvement programmes within hospitals as part of the Patient Safety Friendly Hospital Framework to ensure that patient safety is prioritized and facilities and staff implement best practices. The manual is a key tool for use by professional associations regulatory accrediting or oversight bodies and ministries of health to improve patient safety.
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Technical Brief
HIV patient monitoring and case surveillance
WHO/HIV/2017.11
Technical Brief
HIV patient monitoring and case surveillance
WHO/HIV/2017.12