Medical Record Documentation

Topic: Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality safe care.

Discuss your State Board of Nursing nurse practitioner documentation guidelines and how this can impact your level of reimbursement in the clinical setting.

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400 words

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A medical record can be defined as a legally accepted document that protects the medical practitioners as well as the patients. It is this documentation that is used as a proof of the care given to the patient in a clinical setting. Medical record document should make it easier for an attorney to be in a position to reconstruct the attention given to any patient by viewing that document. Documentation plays a significant role when it comes to communicating on the need for treatment and evaluation services to the third parties and why such services need the vital skill of the speech-language pathologist (SLP) (Sallis et al., 2016). The different States in the United States of America have various guidelines with regards to medical records that have been set out by the Nursing board practitioners. In Florida some of these guidelines are that charting should include the intervention and the response given by the patients. Charting should also be objective but not subjective. In essence, this means that nurse should not chart what they assume or infer. Instead, they should chart what they feel, hear, measure and sometimes what they can also count. The Florida Board……….

APA 516 words