Lesson 1, Topic 1
In Progress

Table 3-1 Essential Elements of Documentation

May 1, 2021

The chart (health care record) has never been more important in the health care system than it is today; it is a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems.

The process of adding information to the chart is called charting, recording, or documenting. Documenting involves recording the interventions carried out to meet the patient’s needs. In the charting of interventions, documenting the type of intervention, the time care was rendered, and the signature and title of the person providing care is essential. Anything written or printed that is a record or proof of activities will, by definition, play a role in this process. Although many details are necessary to remember when documenting in the chart, the process is not difficult but is often time consuming. Good documentation reflects the nursing process. Documentation is an integral part of the implementation phase of the nursing process (see Chapter 5) and is necessary for the evaluation of patient care and for reimbursement for the cost of care provided. In the past, all documenting in the patient’s health records involved written documentation Today a vast majority of facilities use some form of electronic health record (EHR), also sometimes referred to as electronic medical record (EMR). EHRs are used in various settings, including hospitals, long-term care settings, health care provider’s offices, clinics, and home care agencies.

The licensed practical/vocational nurse (LPN/LVN) must understand how to use medical records effectively and efficiently. This chapter covers the purposes for health records, the common types of records, the basic guidelines and rules for documentation, and legal concerns. The knowledge of these guidelines and the ability to chart completely, accurately, and legibly