Medical Record Documentation and Legal Considerations for the Health Care Professional

Course overview

The patient's medical record contains all of the important information about the patient's health, plan for care, and health care progress. The medical record is also the place where health care professionals communicate with each other about patient care outcomes and ongoing treatments, progress and setbacks. The basic purpose of patient care documentation is to produce a clear, concise, and accurate record that allows everyone involved on the health team to know what has happened to the patient, what is planned, and what has been ordered and needs to be done. Proper documentation is essential for best practice. If this information is not recorded accurately the health team caring for the patient will not have the most current and accurate information and patient care and the patient's outcome will suffer.