Documentation And the Medical Record

2 CEUs FREE Online

Purpose :This course provides an overview of the importance of good documentation in the medical record. The medical record documentation is used to communicate about the patient’s course during his/her care in the healthcare environment. Documentation of the patient’s condition can occur in any healthcare setting including the hospital, clinic, doctor’s office, ambulatory surgery center, etc. This course will briefly discuss HIPAA and requirements of The Joint Commission. The overview will include a discussion on the paper chart versus the electronic medical records. Finally, a review of the critical documentation needed should include the nurse’s assessment of the patient, what the patient tells you, and what the nurse teaches the patient. The medical record is a legally binding document. The medical record could serve as a document that is reviewed prior to any litigation by the patient or family members. It is a confidential communication that is used by the people on the health care team that cares for the patient.

Objectives:

  • Discuss confidentiality and HIPAA expectations.
  • Identify the role of nurses and providers in the documentation process
  • Professional and legal aspects of documentation
  • Documentation as a form of legal and ethical communication

Outcome :The healthcare worker who completes this course will have an overview of how the medical record serves to ensure that there is quality patient care provided to the patient and ensures that the patient’s progress is communicated in writing to members of the healthcare team.

It is recommended that the participant who completes this course, also consider taking a future course on comprehensive documentation processes for the medical record.