Medical Charting

Written by Norene Anderson
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Medical charting is one of the latest areas to get on board with technology. Traditionally, everything in the chart is handwritten. The nurse's notes, medication sheets, doctor's orders, patient assessment, and other forms are done when the nurse or physician can get around to it. This often leaves stacks of paperwork to complete when the shift ends leaving room for error in forgotten information.

The advances in medical charting make errors less likely to occur and caregivers have more time to actually devote to care instead of paperwork. Bedside computer access is changing the workload of nurses and other medical personnel. The software is programmed with the standard activities of patient care as well as medications. It takes only a few seconds to check off all information pertaining to the patient and sign off with a digitalized signature. One great advantage is having an up-to-the-minute report on the patient at all times.

Medical Charting Has Changed

Medical charting is also changing in the office of physicians. Computerized forms and voice recognition programs provide a method of developing a chart without the use of a transcriber. When the examination is completed, so is the report. Accuracy is of utmost importance for insurance and billing purposes. The diagnosis and procedure codes must match the content of the examination report. This is possible with integrated software.

Every medical chart must accurately reflect every detail of pertinent knowledge about the patient. Digitally preparing records through the course of treatment makes immediate access possible. All of the information about each patient is stored in electronic format in one database. This makes queries for all kinds of reports possible with just a few keystrokes.


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