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Documentation


Document, document, document!

Importance of medical records


Medical records:
  • facilitate good care
  • allow a subsequent caregiver to understand the patient's condition and the basis for the current investigations or treatments
  • provide a method of communicating with other team members
  • satisfy legal and ethical obligations: medical regulatory authority (College), hospital, and legislative requirements for clear and legible records
  • act as evidence: if your care is later questioned, it shows events as they happened
Explore an eLearning activity on documentation. Opens in new window
A Statement of Completion or CME credits are available.
Explore an eLearning activity on charting medical records. Opens in new window
A Statement of Completion or CME credits are available.