Medical charting tracks patient interactions in a clinical setting. Medical records include demographic information, complaints, test results, treatments, surgeries, and observations. They are used to identify allergies, risk factors, and for insurance and billing. They are also legal documents and require meticulous execution.
Medical charting is the process used to track all interactions with patients in a clinical setting. Every patient has a medical record in which a wide variety of information is recorded from healthcare professionals who interact with the patient. Because many people see multiple doctors, it’s not uncommon for patients to have multiple medical records. In some countries, the preservation of electronic health records has been proposed to avoid this by ensuring that a patient’s entire medical history can be easily accessed.
The information in a medical record starts with the basics: the patient’s name, date of birth, and other simple demographic information relevant to medical care, such as marital status, obstetric history, and so on. The first page of a medical record usually provides this information, allowing the healthcare professional a quick overview of the patient’s basic characteristics. Conventionally, medical records are kept in folders or binders, with pages organized in chronological order.
When someone takes care of medical records, additional records are added to the medical record. Whenever a patient has a problem, the main complaint is recorded, along with the results of the tests, any tests ordered and the treatments used. If drugs are prescribed, the prescription is recorded in the medical record, along with the patient’s response to the drug. Similarly, the medical record includes records of surgeries and other medical procedures, along with observations from healthcare professionals.
Medical charts are essential for keeping track of a patient’s medical history. Caregivers can use a medical record to identify allergies, risk factors for various diseases, and other problems that may be immediately relevant to treatment. The history in the medical record can also be evaluated when establishing the patient’s plans and discussing options with the patient. Medical records are also used as a basis for the provision of insurance benefits and billing.
For hospitalized patients, medical records provide a means of communication for healthcare professionals. Nurses record vital signs and note when medications were administered, along with other noteworthy information, while physicians record the outcome of patient meetings and procedures. The medical record also includes signed consent forms and other legal documents related to patient care.
Medical records are also legal documents. Every piece of information in a medical record can be used in a legal case, ranging from a malpractice lawsuit against a doctor to a lawsuit against a pharmaceutical company over a defective drug. For this reason, people receive special training in medical charting during their medical education, learning a standardized format for charting, and being knowledgeable about the legal ramifications of charting.
Many medical professionals dislike medical records, as they must be meticulously and very carefully executed to ensure that all relevant data is recorded. Missing a step in the medical record can be legally dangerous and potentially harmful to the patient. For example, if a nurse administers a medication and fails to record it, another nurse may notice that the medication was ordered but not administered according to the schedule, and the medication would be administered again, putting the patient at risk.
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