Patient Documentation And Medical Procedures

1684 WordsNov 11, 20157 Pages
Patient documentation is a fundamental component in healthcare. It is important to document the patients’ condition, and any provided care to ensure the patient receives quality care. Unable to document properly can often cause serious injuries or sometimes death. This often results in adverse healthcare outcomes and legal proceedings for malpractice. There has been serious malpractice issues caused by improper documentation, where the patient is subjected to unnecessary medical procedures. Documenting medical records serve as a legal document that can aid in any legal action. Updating current patients’ health status helps to communicate proper care plans, medical procedures, and medical treatments. Patient documentation is relied upon accuracy, all information is expected to be accurate and relevant. As a Certified Nurse Assistant I was expected to document all provided care with accuracy and in a timely manner. I worked in an Orthopedic Rehabilitation Center, that specialized in short-term care for individuals recovering from hip and knee surgery. I had various duties to perform, the most important was to document patients information into a computer system. At work I was always assigned to take care of eight patients’ I was responsible for providing excellent customer service and care. All patients were on medications, some which required to have their vital signs checked before consuming medication. I was responsible to check the vital signs of all of my assigned
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