Having a comprehensive and well utilized medical risk management documentation process embedded in your facility's day to day operations plays full-proof the defensibly of your practice and staff, provides measurable evidence of patient progress and creates a standardized, systematic approach for every stage and step of patient care. That said, UHC understands the need to streamline and reduce administrative paperwork and increase time providing direct patient care.
UHC develops risk management, quality assurance and compliance programs that utilize efficient, intuitive and thorough documentation policies and procedures. We design documentation forms and worksheets tailored to your practice, staff and practice culture so they will be easy to use and establish a documentation standard within your practice that reduces preventable risks, improves patient care and leads to greater patient satisfaction.
UHC works with a wide variety of single and multi-specialty facility types. Each facility has a unique set of documentation needs and requirements based on the procedural treatments performed In addition, each facility has a unique set of documentation needs and requirements based on the individual style and strengths of each practice. UHC works with clients to create or revise documents that, in addition to meeting federal, state and regulatory compliance standards, are designed for optimum usability, and patient and staff protection. UHC audits and evaluates current documentation processes, meets with staff to understand work flow, individual roles and responsibilities and gather information regarding usability of, and challenges with, current documentation forms and processes. Medical records are legal documents serving as viable evidence of what transpired between patient and doctor, patient and nurse and other staff.
Creating or revising a comprehensive portfolio of documentation forms in addition to policies and procedural training and monitoring around those documents is a vital key to reducing preventable risks and increasing the quality and safety of your patient care. UHC works with clients to integrating a documentation process that feels natural, intuitive and enhances the flow of direct patient care. UHC's risk management program establishes and monitors client documentation to measure risk reduction, improve quality assurance measures, track and trend occurrences, generate benchmark studies, complete adverse incident reporting and submit required QA reports to your governing body, state or federal regulator.
UHC works with new facilities to evaluate and determine a documentation profile and portfolio specific to your specialty, accreditation goals and state and federal regulators. We create the necessary documentation forms and worksheets for our clients to begin using on the first day they open their practice. UHC establishes policies and procedures and trains staff on documentation protocol, in addition to creating policy and procedures manuals for your practice, aligned with the documentation process. We give you the documentation tools you need to start your practice off on the right risk management foot from day one. UHC monitors your documentation usage, usability and efficiency and revises forms and/or policies surrounding the documentation process to refine quality assurance, improve safety practices and reduce preventable risks. The overall goal of your documentation process is to reduce risks and improve patient care. UHC helps you achieve that goal while creating a process for your documentation protocol that is intuitive for you and your staff, reduces paperwork and increases time spent providing direct patient care.