1
Q
what are medical records?
A
communication tool that tracks the patient’s medical history and care received
- allows for evidence-based practice (see what worked in the past, what didn’t)
2
Q
what is the role of medical records?
A
- legal documentation that can be used as evidence in court
- provides proof whether standard of care was met or not
3
Q
what is the difference between electronic medical records and electronic health records?
A
EMR = electronic version of paper record that is office based; records that doctors have in their office
EHR = “netcare”; collective data from multiple sources (need username and password to access)
4
Q
what are some charting standards?
A
- patient-centered
- relevant, clear, concise and comprehensive
- confidential
- permanent and retrievable
- accurate, legible and free of spelling and grammar errors
- CHRONOLOGIAL and timely
5
Q
what are charting “do’s”?
A
- black and blue ink pens only
- mistake? cross out once and mark with “error” and sign next to the error
- all entries to end with signature and credntials
- chronological
- no blank spaces!
6
Q
what is required for inpatient charting?
A
- verification of id
- if you administered anything (radiopharm, route)
- preparation instructions for other hcp
- condition of patient throughout the exam
- time, date, signature and credentials
