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Pages:
1 page/≈275 words
Sources:
3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 4.32
Topic:

Patient Charting Every Healthcare Practice

Essay Instructions:

Discuss the correct way of charting in a patient’s record. Analyze the impact of poor documentation in patient care? Give one or two examples. Explain possible legal concerns for poor documentation.

Essay Sample Content Preview:

Patient Charting
Your Name
Subject and Section
Professor’s Name
May 10, 2019
Patient charting is an indispensable process in every healthcare practice. It helps medical professionals, working on different capacities, to ensure the best treatment for their patient even without communicating directly about the treatments that were already done, the recommended procedures to be done, as well as other pertinent information about the patient himself. However, because of the ‘indispensable’ nature of patient charts, any mistakes in documentation or interpretation could lead to severe drawbacks. This simply shows that any patient chart must be made with accuracy and timeliness, in order to ensure that the best treatments are being given to the patient.
There are many ways in order to streamline the process of patient charting, and the succeeding ones are just some of them. First, a patient chart must always have the ‘6 C’s’, namely cause of the symptoms, chronic conditions, clinical significance of abnormal test results, check laterality (note right or left side), clarity of patient’s mind, and current state of patient and treatment CITATION Scund \l 1033 (Sculley, n.d.). Second, the doctor or any practitioner must be made aware of the critical nature of good charting techniques,...
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