Record Keeping For Patients
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Discuss the correct way of charting in a patient’s record.
Analyze the impact of poor documentation in patient care? Give one or two examples.
Explain possible legal concerns for poor documentation
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A discussion of the correct way of charting a patient’s record
Any records that relate to patients in a medical facility must be as accurate and as objective as possible. Coming up with patient’s records becomes much easier when standardized forms are used. The forms ascertain that there is consistency and high quality records are produced. The records should always include a patient identification sheet. The identification sheet provides patient bio data. Continuation sheets should always be available in case some additional information is made available by the patient………………………….words 538