The Importance of Documenting Patient Status and Care

621 WordsFeb 2, 20183 Pages
Documentation of patient status and care is important for a variety of reasons. First, it allows health care professionals to plan and evaluate treatment. Health care records are also used as a communication tool by multidisciplinary teams. Documentation is also used as evidence in legal matters, and for reimbursements. Health care agenizes also use electronic health record data to study and improve future care. Because there are so many things that health records are used for there are important things you should be sure to include. When documenting the most crucial parts is documenting interventions and the patients reactions to chosen interventions. If there are any significant events or changes in the patient or the plan it must be documented. Always be sure to document if and when informed consent for procedures and actions is needed. If the patient refuses treatment or leaves against medical advice be sure to document. Medications are always documented along with any "occurrences" such as medication errors or falls. Most importantly always include the date and time on all of the notes. With all this information that should be included in documentation it is helpful to sort it into subjective and objective data. Objective data is going to be something that is gathered through physical assessment or from lab and diagnostic tests. Most objective data can be measured such as vital signs. Subjective data is information given to the nurse by the patient or a family
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