1. Documentation in healthcare
Medical Therapeutics

2. Medical Therapeutics Standard
10) Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through: 
a. History and Physical including but not limited to: family, environmental, social, and mental history
b. Brief Head to Toe Assessment noting normal vs. abnormal findings 
c. Vital Signs Assessment (VS)
d. Height/weight, BMI /Calculation
e. Specimen Collection

3. Objectives Explain the importance of clinical documentation
Provide principles of documentation
Describe the contents of the medical record
Discuss how documentation impacts quality of care, financial planning, healthcare outcomes and appropriate reimbursement

4. Documentation Matters!!

5. Contents of a hospital medical record
History and Physical (admission note)
Emergency room documentation (if any)
Progress notes
Nursing Notes
Operative reports (if any)
Medication record
Flow charts
Lab and radiology reports
Orders
Discharge summary

6. Why is documentation important, anyway?
Documentation is critical for patient care
Serves as a legal document against claims of negligence, improper treatment or omission of care
Provides evidence for quality reviews
Validates the patient care provided
Impacts coding, billing, and reimbursement

7. Principles of documentation
Complete and legible
All entries should be dated and authenticated by provider
Documentation of each patient encounter
Date and reason for encounter
Appropriate history and physical including any present problem
Assessment and plan of care
Explanation of treatment
Any other relevant information

8. In a nut-shell Clinical documentation should be: Complete Legible
Timely
Concise
Clear
Patient Centered
Accurate

27. REMEMBER:

28. How do we use this information? Applying what you learn.
Each group will research the documentation requirement and styles of an assigned therapeutics career.
Create a PowerPoint summarizing your information to present to the class
Demonstrate application of proper documentation techniques researched by creating a situation in which you would document using the researched style.
Create a chart entry using your researched style to turn in to Ms. Corbin