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The patient’s medical record contains all of the important information about the patient’s health, plan for care, and health care progress. The medical record is also the place where health care professionals communicate with each other about patient care outcomes and ongoing treatments, progress and setbacks. 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 to the patient, what is planned, and what has been ordered and needs to be done. Proper documentation is essential for best practice. If this information is not recorded accurately the health team caring for the patient will not have the most current and accurate information and patient care and the patient’s outcome will suffer.
After completing this inservice, the learner will be able to:
- Identify three aspects of proper documentation
- List three things that a healthcare professional may document about their patients
- Describe the proper way to document a note that is entered late
- Patient Care Documentation - The Basics
- Guiding Principles of Patient Care Documentation
- Safe and Appropriate Patient Care Documentation
- What is Appropriate Documentation?
- Good and Bad Examples of Documentation