Outcome 7

Question 1

what are medical records?

Answer 1

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)

Question 2

what is the role of medical records?

Answer 2

• legal documentation that can be used as evidence in court
• provides proof whether standard of care was met or not

Question 3

what is the difference between electronic medical records and electronic health records?

Answer 3

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)

Question 4

what are some charting standards?

Answer 4

• patient-centered
• relevant, clear, concise and comprehensive
• confidential
• permanent and retrievable
• accurate, legible and free of spelling and grammar errors
• CHRONOLOGIAL and timely

Question 5

what are charting “do’s”?

Answer 5

• 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!

Question 6

what is required for inpatient charting?

Answer 6

• 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