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Title

Medical Charting and Documentation, Part 2: The Documentation Process (1 credit hours)

Abstract

This module discusses important documentation characteristics addressed by accrediting agencies, identifies the most common procedures used for proper documentation and describes common problems associated with charting medical information in a variety of health care settings.

Planners, content specialists and feedback personnel have declared that there is no conflict of interest in the preparation and content of this module. There is no commercial support for or endorsement of products in this module.

Author

Katherine Ott, MSW, ELS

Katherine Ott, M.S.W., ELS, is a managing editor for the American Society of Radiologic Technologists and a certified Editor in the Life Sciences. She has written and edited several articles on medical imaging and radiation therapy for various ASRT publications.

Barbara Wallace, RHIA, CCS, CCS-P

Contributing Author
Barbara Wallace is an associate professor of Health Information Management at Sinclair Community College (Dayton, OH). She has over 12 years experience as an HIM educator and 14 years experience as a department director and vice president in the healthcare industry.

Objectives

After studying the information presented, the reader should be able to:

Articulate important documentation characteristics addressed by accrediting bodies and legal entities and apply general rules to each.
Describe the most common charting problems.
Describe documentation practices applicable to the dialysis unit.
Identify procedures for charting common events such as vital signs, medication administration, IV therapy, dialysis therapy and incident reports.

Resources

Bibliography

Abdelhak, M. Health Information: Management of a Strategic Resource. Philadelphia, PA: W.B. Saunders Co;1996:135-141.

Bruce JAC. Privacy and Confidentiality of Healthcare Information. Chicago, Ill: American Hospital Publishing Inc; 1984:7-18.

George, JE. The emergency department medical record. Emerg Med Clin North Am. 1993; 11:889-903.

Huffman EK. Health Information Management. 10th ed. Berwyn, Ill: Physicians' Record Company; 1994.

Iyer PW; Camp NH. Nursing Documentation. St. Louis, Mo: Mosby Year Book Inc; 1991: 102, 105-107.

Mastering Documentation. Springhouse, Pa: Springhouse Corporation; 1995.

Medical Economics. July 10, 1995.

Magnuson, J. Documentation in the Dialysis Unit. Renal Link, 2000, 1(4): 1, 17-18

Southwick AF. The Law of Hospital and Health Care Administration. Ann Arbor, Mich: Health Admini stration Press; 1978:298-345.

Webliography

General Info

Page Name: Medical Records Institute
URL: http://www.medrecinst.com/
Notes: Homepage of Medical Records Institute. Good resource.

Documenting Common Events

Page Name: Vital Signs
URL: http://www.medinfo.ufl.edu/year1/bcs/clist/vitals.html
Notes: A good guide to taking and understanding a patient's vital signs.

Page Name: Pitfalls of IV Therapy
URL: http://medi-smart.com/pitfalls.htm
Notes: Article on potential legal problems associated with IV Therapy. Article urges proper and thorough documentation of IV Therapy to avoid malpractice litigation.

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