Learning how to accurately and appropriately document patient information, including medical history, vital signs, and care plans.
Medical Terminology: Understanding medical terminology is vital when documenting patient care. It provides an accurate vocabulary to describe symptoms, diagnoses, treatment plans and more.
Electronic Health Records: Electronic health records (EHRs) have replaced paper records in many healthcare facilities. Learning how to navigate EHRs and document patient care within them efficiently is crucial.
Legal Requirements: Understanding the legal and ethical obligations of documentation is essential, including HIPAA regulations, informed consent, and patient confidentiality.
Charting Formats: Charting formats vary between healthcare organizations, but it's important to learn charting methods used within your facility. The SOAP (subjective, objective, assessment, plan) method is a commonly used format in healthcare.
Progress Notes: Progress notes are where healthcare professionals document patient care daily. Learning how to document accurately and efficiently is crucial.
Medication Administration: Properly documenting medications is critical in patient safety. It includes medication orders, administration times and routes, and any adverse reactions.
Regulatory Compliance: Healthcare facilities must comply with regulations set by accrediting agencies, such as the Joint Commission. Understanding the requirements for documentation compliance is vital.
Patient Assessments: Accurate patient assessments inform the care that patients receive. Documentation of those assessments provides continuity of care across the patient's episode of treatment.
Therapeutic Interventions: In some cases, nursing intervention and/or other therapies are required to support healing, recovery or improved quality of life, such as nutrition, sleep management or pain management.
Communication Skills with Colleagues and Patients: Effective communication is essential when documenting patient care. Learning how to document and convey messages effectively and accurately can improve the quality of care delivered to the patient.
Medical History: A record of a patient's past medical conditions, surgeries, illnesses, and treatments.
Physical Exam: Documentation of a patient's current physical appearance, vital signs, and any abnormalities.
Medication List: A list of all the medications that the patient is currently taking, including dosage and frequency.
Diagnostic Tests and Results: Reports of tests, including laboratory results and radiographic images.
Progress Notes: Comprehensive documentation of a patient's care during hospitalization, including assessments made by the medical professional, interventions, and patients' responses to treatment.
Care Plan: A detailed plan outlining what care a patient needs and how to provide it. It includes goals, interventions, and expected outcomes.
Informed Consent: Documentation indicating that the patient has given informed consent for specific procedures, including an explanation of the benefits, risks, and alternatives available.
Discharge Summary: A summary document that provides the patient with information about their hospitalization, including diagnosis, treatment provided, and instructions for follow-up care.
Operational and Communication Logs: Records of all types of internal communication between healthcare staff, including the duration of shifts, hospital rounds, and surgical procedures.
Billing Documents: Includes invoices for medical procedures or therapies, insurance claims, and reimbursement documents.
Legal Documents: Includes medical releases, power of attorney forms, and advanced directives that guide end-of-life care.
Orders: Physician orders that outline specific care interventions, interventions, and treatment documentation.
Nursing Assessments: Records of patient history taken by a nurse, including the assessment of vital signs, discomfort levels, and behaviors.
Consultation reports: Reports of patients referred to specialists with key details on the condition and concerns of the patient.
Scanned Documents and Images: Radiographs, MRIs, patient records and other documentation are scanned into a patient record to make them easily accessible.