MEDICAL RECORD DOCUMENTATION AND LEGAL CONSIDERATIONS

Course overview

The patient medical record contains all of the important information about the patient's health and progress. The medical record is also the place where health clinicians communicate with each other about patient care outcomes. The basic purpose of patient care documentation is to produce a clear, concise, and accurate record that allows everyone involved in the health team to know what has happened, what is planned, and what needs to be done. Proper documentation is essential because if this information and those events are not recorded, no one on the health team caring for the patient will know what has happened and patient care and outcomes will suffer.