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The Documentation of Medical Records

25 Pages | 5,084 Words
Brenda Grant, MS (#110276)

This eBook describes the important components of Medical Record documentation. It will guide you through the process of documenting a patients' medical history, whether you are using Electronic Medical Records (EMR) or physical charts. A variety of concerns and integral parts that make the medical record of extreme importance today more than ever before are addressed within this eBook. Reading this eBook will provide you with guidelines and tools, and arm you with knowledge that will allow you to be more comfortable and confident when the need arises to provide documentation of patient care.

An Introduction to The Documentation of Medical Records

Writing is a skill set: a simple but true statement. It is something learned and is actually a complex activity. Within a patient s medical record substance is the main concern. When documenting in a medical record, remember that this written record will endure.

The variety of entities one accesses to write in, such as social media and
e-mail, has caused our attitudes to become more relaxed when writing. Remember, however, when writing in a patient s medical record it is imperative that our attitudes are not relaxed; instead, we must pay attention to detail so that the record of care will be both complete and understandable.

Within the pages of this eBook you will find a multitude of information that is easy to read and refer back to as you embark upon your career in the medical profession.

In an effort to make this an easy-to-use guide for documenting within a medical record, the content is simply formatted. You will learn what makes the medical record important, documentation guidelines to follow, and a little bit about the department that maintains the record.

The eBook is completed with a quiz, appendix, glossary, and references. You will find these things to be an asset to you not only during this educational process, but throughout your career as well.

About the Author

Brenda Grant, MS

Active since Dec 2011

Brenda Grant holds a Bachelors Degree in Business Administration and Masters Degree in Education. Employed for the past 18 years by a community mental health agency at which she has held a variety of positions. Since 2004 she has held the dual position of Medical Records and Human Resources Manager. These positions require her to maintain the most recent information regarding the medical records department as well as information that are important and affect the Human Resources Department. Ms. Grant provides medical and clinical staff trainings on proper documentation in the medical record; supervision; and a variety of other training topics such as terminations; FMLA; HIPAA; Releases of Information; Alcohol and Drugs in the Workplace; Discrimination; Cultural Diversity; and a host of other topics. Brainmass is a source of enjoyment for Ms. Grant having utilized it as both a student and an instructor she is dedicated to assisting others in the accomplishment of their educational goals.

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