1. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.1

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3. 3 Definitions Medical documentation Medical record Charting

4. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.4 Purposes Contributes to good patient care Provides legal protection Helps ensure regulatory compliance Improves cost control Decreases denials from insurance companies

5. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.5 Characteristics Complete Concise and factual Properly identified Legible Correct spelling, terminology, punctuation, and grammar

6. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.6 Characteristics Clearly and objectively expressed Do not duplicate findings Use approved abbreviations listed in facility’s policy Time and date all entries

7. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.7 Characteristics Signed by the proper person Complete without leaving empty lines Never chart in advance of giving medication or performing procedure Written with black or blue ink

8. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.8 Making Corrections Draw a single line through error Write in correct information Note error per facility policy Date and initial correction Correct immediately on computer If discovered later, correct as above

9. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.9 Medical Records Organized per facility policy All health care workers are responsible to maintain the records per facility policy Chronological or source oriented

10. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.10 Medical Records Contents History and Physical (H&P) Physician’s orders Diagnostic tests Admissions Surgical procedures Graphics

11. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.11 Medical Records Content Flow sheets Medications record Progress notes Reminder –Verify correct form in chart by ensuring patient’s name is on each document

12. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.12 Medical Records Content Each section will be chronological Thinning a chart Security of files

13. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.13 Progress Notes Primary tool –Recording, communicating, and coordinating care of patient May include: –Observations –Treatments –Patient response

14. Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.14 Progress Notes—Formats Problem-oriented charting Narrative charting Charting by exception Computerized