(HIM) Lesson 1: Healthcare Records

Lesson 1: Healthcare Records

Written observations and information about a patient in a healthcare setting are called charting. The nurses chart information in the "nurses' notes" section of the chart while the physician and other departmental personnel place notes in the "progress notes" section. We will now explore how medical records are managed and organized.  

Please watch the following presentationDocumentation is a record of the patient's progress throughout the hospitalization or treatment period. Reporting changes in an individual's behavior or health status is the responsibility of all healthcare workers, although recording information in the chart is allocated to specific professions.  

All medical records documents must contain the person's name, age, address, diagnosis, and identification number.

Documentation on patient-related treatments should be specific including the

  • Time of Treatment
  • Treatment given
  • Patient's response to treatment
  • Observations that may be beneficial to the total care of the patient

Documentation Requirements

Remember, if it is not written, it did not happen image

  • Black ink for all documentation unless otherwise indicated
  • Use clear, legible handwriting
  • Entries should be short and concise. Complete sentences are not required, but they should be descriptive of the event
  • All entries are followed by the health professional's signature

Errors

  • Do NOT erase, scratch out, or cover errors
  • Draw a single line through the error
  • Write the error next to the entry with your initials and date (if required)

The patient's gait was steady, a line drawn through the word steady and followed by the word error/SW, then replaced with the words, slow and unsteady, during ambulation.

 

[CC BY 4.0] UNLESS OTHERWISE NOTED | IMAGES: LICENSED AND USED ACCORDING TO TERMS OF SUBSCRIPTION