University:
Pearl River Community College
Course:
4620 | Nursing
Academic year:

2023
Views:

439

Pages:

1
Author:

wasiibebg9q

MEDICAL RECORDS–DOS AND DON‘TS Medical records are essential documentation in every health care setting. They notate the instances of care between health care personnel and clients. Communication Reimbursement Research Dos Legal documentation Education Auditing/ monitoring Don’ts Double-check to make sure you have the correct client chart. Do not record personal opinions or views, such as “the client needs to lose weight.” Make sure to use your name/your account when charting. Do not chart on behalf of other health care personnel. Keep your password safe and secure. Do not share your login information. Chart in real time or as soon as possible after taking care of a client. Do not chart ahead of time, as situations can change. Likewise, do not alter prior charts. Chart facts, such as “the client ambulated 100 steps today.” Do not copy and paste information from other sections in someone’s chart. Chart interactions with other healthcare personnel, such as calls to doctors or orders from the lab. Do not chart interactions that are not relevant to your client care, such as “awaiting voicemail” or “orders pending.” NOTES

Nursing CS Medical Records Dos and Donts

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