Medical Charting Documentation

Written by Norene Anderson
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Medical charting documentation is a critical part of patient care. Accurate documentation is crucial in providing the physician or caregiver the information needed for continuity of care. A lot of information is contained in the medical chart in the hospital and in the physician's office. Stringent guidelines are in place for the appropriate use in both localities.

In the physician's office, it is often up to the nurse or technician to enter data into the chart as the examination is in progress. Many doctors dictate findings in a defined order that coincides with a form making it easy for the assistant to fill in every detail. Other physicians prefer to do the complete examination and then dictate a report of the findings for a transcriptionist to enter on the appropriate form.

More Information on Medical Charting Documentation

In the hospital setting, medical charting documentation is done by a variety of people. A patient may be seen by a respiratory therapist, dietician, social worker, chaplain, or any of many medical professionals and support systems. Each of these must chart every encounter with the patient and include the results of the encounter. Special forms are provided in the medical record for each department. In locations using digitalized medical records, the information is immediately stored as part of the permanent record.

The great advantage to digital medical charting documentation is the convenience of finding information when it is needed with just a few clicks of the mouse instead of thumbing through pages of written document. This is particularly useful for locating lab results or other data that is sometimes needed in a hurry. The software can be set up where access is allowed only for those with the proper credentials and password. This guarantees privacy for all patient information.

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