The Importance of Proper Chart Documentation
One of the most important things you will do in your job in the healthcare profession is charting. Charting is the way healthcare professionals communicate a patient’s weight, height, condition, medication, and past medical history. As soon as you walk in a doctor’s office, hospital, or any medical facility charting begins from the moment you sign in. Only healthcare professionals that are certified, licensed, or registered to chart should do so. There are three reasons proper chart documentations are important: to avoid lawsuits, keep accurate medical information for patient, and to maintain proper communication from one professional to another.
Avoiding Malpractice Suits
People sue for a lot of reasons today, and one of them just happens to be improper charting that causes errors. Attorneys on the plaintiff side gather every chart and record that was made during the time in question. The proper chart documentation can either be the nail in the coffin for a case, or the factor that decides wrong doing and monetary compensation. It is imperative that documentation is done thoroughly and properly every time data is recorded. Any time a patient calls, misses an appointment, or very difficult and aggressive it should be recorded in their chart. It is important that all information pertaining to the patient be recorded in case there is a question about proper documentation.
Availability of the Correct Information
Most offices, facilities, and practices in the healthcare field have operating hours with more than one shift. A patient may be in need of the date a Hepatitis B vaccination was given or inquiring about their next appointment. It is important that proper chart documentation has been prepared so that this information can be at the fingertips of whoever happened to be on shift. Some patients may only be able to get shots every 6 weeks according to a certain medications, so the date they...