Healthcare Documentation

INTRODUCTION
The project that I chose to discuss in this paper is how important proper documentation is in the world of healthcare. The purpose of this project is to teach the healthcare professionals and medical staff that are employed within nursing homes, hospitals, assistant living, rehabilitation centers and clinics on the importance of proper documentation. The purpose of this project is to bring cognizance to the topic while implementing helpful information and guidelines for the medical professionals and staff to understand and follow.
BACKGROUND
In the healthcare industry, it is important for all healthcare professionals and medical staff to understand the importance of proper documentation. Clinical record keeping is an vital factor

By documenting all important clinical information you are recording this information for future situation. If something is not documented, it did not happen. This is of certain significance in the case of a questioned medical decision but most importantly it guarantees continuity. Continuity is vital importance in clinical notes of patient care as, in the existing medical environment, different healthcare professionals are associated in the treatment of a patient. That is why it is so important to make sure that clinical notes are up to date and accurate with appropriate information. This will help confirm that the proper information is provided to all healthcare workers and will help to make any future decisions. Patients will benefit in less time lost on test being repeated and by preventing wrong diagnoses or the prescription of wrong treatments. Healthcare organizations have a benefit when good clinical records smooth decision making for patients, this allows them to have more time with patients. Poor clinical records might have a deep effect on a patient’s health in the long run. The seventh principle of the Caldicott report, an NHS report on patient information, states “the duty to share information can be as important as the duty to protect patient confidentiality (Mathioudakis et al,

Data Collected
“If it’s not documented in the medical record then it didn’t happen.” This is so important. This is your word saying that a task was performed. It should be recorded with a date and a time.
Interpretation
Documenting is very important. It is a person’s whole life story. It is very important for any medical staff treating a patient to document and record everything properly. The patient’s life is in your hands. Putting in information that is not accurate can do more harm than good.
Conclusion/Application
In conclusion, one cannot stress enough how important documenting the correct information in/on a patient’s chart is. The information you chart should be accurate and true. The patient’s chart is their whole life story. It contains pertinent information about them. Putting in wrong information can do harm to them and cause problems for a facility. So it is best to chart only what task your