A‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ student post this as a discussion post, please reply with

A‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ student post this as a discussion post, please reply with 1 up to date reference. According to The American Association of Nurse Practitioners (2019), a nurse practitioner maintains accurate, legible, and confidential records for patient status and care. Records include assessment of health status; diagnosis; development of a comprehensive plan of care; implementation of the plan; follow-up and evaluation of the patient status; patient and family education; facilitation of shared decision making and participation of the patient/family in health care decisions; and promotion of optimal health. The link https://dhcfp.nv.gov/uploadedfiles/dhcfpnvgov/content/Pgms/LTC/MSM_500_16_08_11_Attachment.pdf shows the documentation guidelines in the state of Nevada. The guideline is not solely used by the nurse practitioners but also utilized by physicians, physician assistant or clinical nurse specialist (Nevada Department of Health and Human Division of Health Care, 2016). It is important to document accurat‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ely for proper reimbursement as well as patient care and safety. Not only that documentation is important for reimbursement but also in litigation or any other legal action concerning patient care, observations, assessments, and interventions. Clear documentation is important in any type of billing. Each practitioner mush detail and document the care they provided to substantiate reimbursement. Regulations vary by insurance companies and states. That being said, providers must stay current with practice guidelines and ongoing changes (American Nurses Association, 2021). My preceptor shared an experience last year where a colleague of hers did not “Lock” her charting and was told that Medicare and Medicaid would not reimburse a month worth of services due that incident. “Locking” means after they charted and signed, providers are unable to make changes because the documents are sent for billing. Since the colleague neglected to lock the documents, unfortunately, the organization lost $100,000 worth of ‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍services.

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