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Documentation


Document, document, document!

Overview and objectives


Animation of superhero figure holding medical record

Overview

Medical records contain the personal health information of patients. Whether in written or electronic form, records are central to patient care and safety. Medical records permit communication within the circle of care
Circle of care:  The group of health care professionals providing care to a patient who need to know the patient's personal health information to provide that care.
 when verbal communication isn't possible. The record offsets the fallibility of memory and is permanent, so subsequent readers can see what took place.

This topic reviews some of the reasons for taking the time to document carefully, and gives some suggestions for doing so effectively.

Objectives

After completing this topic you will be able to:
  • Identify 5 elements of a good clinical note.
  • State 3 uses for a clinical note.
  • State 3 ways in which a clinical note promotes patient safety.
  • Identify 5 potential groups of readers of your clinical note.