Medical Records Documentation
The patient’s medical record contains all of the important information about the patient’s health and progress. The medical record is also the place where health clinicians communicate to each other about patient care outcomes. The basic purpose of patient care documentation is to produce a clear, concise, and accurate record that allows everyone involved on the health team to know what has happened, what is planned, and what needs to be done. Proper documentation is essential because if this information and those events are not recorded, no one on the health team caring for the patient will know what has happened and patient care and outcomes will suffer.
After completing this inservice, the learner will be able to:
- Identify the first and most important rule of medical documentation.
- Identify three aspects of proper documentation.
- Identify the three “don’ts” of proper documentation.
- Identify a CNA note that is an example of good documentation.
- Identify the proper way to document a note that is entered late.
- Patient Care Documentation: The Basics
- How to Document Correctly
- What Will You Be Documenting?
- Good and Bad Examples of Documentation