Explain the importance and legality of charting


Charting or documenting is essential to health care. If a malpractice case were to be filed, the health record could be your best friend. It will show the date and time you performed the procedure, and all the therapies performed. This is why it is good to include as much detail as possible and also to assess your patient's status to the fullest. Each patient has a health record which is a legal record that contains biographical data, medical histories, physician orders, physical exam and diagnostic test results, and assessment and progress notes from various health care disciplines. Due to the personal and sometimes sensitive information contained in a health record or during conversations between health care professionals, confidentiality must be maintained.

Health Professions

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Health Professions