Documentation and Medical Records
What is documentation? notes and documents that hcp add to medical record
So what is the purpose of medical documentation?
What are characteristics of GOOD medical documentation?
How do you make corrections in medical records?
What is some information that you find in a medical record?
progress notes- there are different formats all with advantages and disadvantages
purpose- legal protection
decrease denial from ins co. omg my dad!!
facts and concise-what does concise mean?
properly labeled and ID on q page
no double charting
only approved abbreviations
signed by person doing charting
completed with no empty spaces
no charting in advance-ever
black ink/ maybe blue-THATS IT! no red no pencil
CORRECTIONS ON MED RECORDS
put correct info next or close to
error if facility policy
date and initial
almost a non issue w computers
contents of records
H & P
hx- familial, social, and personal-what do these mean?*
surgical reports and consents
progress note-chronological, every time pt is seen, to update findings and plan for care,
this is written by..any one who provides care to patient*
Charting-you record observations and info about your pt-EVERY SINGLE ENTRY YOU MAKE NEEDS TIME/DATE/SIGNATURE 2/23/15 0700 MHudecek RN
if you chart by exception what does this sound like?
Assessment-our view or opinion about pts problem "I Assessed..."
Chief complaint-what do you think this is?