Lesson 1, Topic 1
In Progress

Objectives

May 1, 2021

1.List the five purposes for patient records.

2.Describe the electronic health record (EHR) and the personal health record (PHR).

3.Determine when the use of Situation, Background, Assessment, and Recommendation (SBAR) is beneficial.

4.State important legal aspects of chart ownership, access, confidentiality, and patient care documentation.

5.Describe the differences between traditional and problem-oriented medical records.

6.Describe the basic guidelines for and the mechanics of charting.

7.Describe the differences in documenting care with activities of daily living and physical assessment forms, narrative, SOAPE, and focus formats.

8.Discuss documentation and clinical (critical) pathways.

9.Discuss home health care documentation.

10.Discuss long-term health care documentation.

11.Discuss issues related to computerization in documentation.