The Medical Field, No Observation Goes Without Documentation

1369 WordsMar 13, 20176 Pages
In the medical field, no observation goes without documentation; in other words, if it was not documented, it never happened. Therefore, health care professionals must place a great importance on where, when, and how he/she records patient information. Traditionally, patient data has been filed papers kept by the hospital but in the last eight years, hospitals have been encouraged to transfer to Electronic Health Records (Balestra). Electronic health records are digital sources of patient information and personalized care strategies (Seidman). Previously, a nurse would be prompted to physically write down vitals and other similar information onto a chart in the patient’s vicinity but with the introduction of EHRs, this report is now done…show more content…
After giving her case on the dilemma of EHRs, Balestra concludes her article with tips for medical professionals on how to successfully operate these records without producing these issues. Published works have many obstacles they need to overcome to be successful. Authors, such as Melanie Balestra, must make logical and effective writerly choices to create a strong article or publication. As mentioned previously, Balestra is a part of the medical professional community which is helpful mostly due to the credibility it provides her with an audience of mostly people in the health care field. Along with that credibility, Balestra’s profession grants her insider knowledge of her audience and what they look for in a published piece; this knowledge allows her to make writerly choices that cater specifically to nurses and other health care professionals. Through the partly medical jargon, IMRAD-like structure, and multimodal aspects used in her article, Balestra solidifies a sense of comradery between herself and her audience. It is not uncommon for medical terminology to be viewed as dense or confusing by the public, but to someone in the health care field, those terms are just every-day words. Balestra understands this notion and addresses it thoroughly to create the most comfortable setting for her entire audience. In general, it is easier for one to understand an unfamiliar jargon when context clues are available. Adding common terms near
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