Medical Record Documentation and Legal Aspects and Assistance with Self Medication

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The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one particular health care provider’s jurisdiction.[1] The medical record includes a variety of types of “notes” entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.[2] This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.

A medical record folder being pulled from the records

Because many consider the information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal.[5] Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.

Course Features

  • Lectures 12
  • Quizzes 1
  • Duration 6.0 Hour
  • Skill level All level
  • Language English
  • Certificate Yes
  • Assessments Self
  • Medical Record Documentation and Legal Aspects

    • Lecture 1.1 Introduction Preview 30m
    • Lecture 1.2 Nursing diagnoses, interventions, and outcomes Locked 30m
    • Lecture 1.3 Health Insurance Portability and Accountability Act (HIPAA Locked 30m
    • Lecture 1.4 Charting guidelines Locked 30m
  • Types of documentation

    • Lecture 2.1 Flow sheets Locked 30m
    • Lecture 2.2 Narrative Locked 30m
    • Lecture 2.3 Source-oriented Locked 10m
    • Lecture 2.4 Problem-oriented (SOAP) Locked 30m
    • Lecture 2.5 Focus (DAR) Locked 30m
  • Critical pathways

    • Lecture 3.1 Critical pathways Locked 30m
    • Lecture 3.2 Computerized Locked 30m
    • Lecture 3.3 Summary Locked 30m
  • Quiz

    • Quiz 4.1 Medical Record Documentation and Legal Aspects Locked10 questions
  • The quiz is not a requirement for this course. You only need to mark all sections complete. Then click on profile, scroll down you will see where it completed courses, there's a link there that said your certificate, click on it and print your certificate. Or in in your transcript, in your profile, you can print your certificate there also.


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