Charting

Definition

Charting is the systematic recording of a patient's medical history and care by healthcare professionals. It ensures accurate communication and documentation of patient data for legal and clinical purposes.

5 Must Know Facts For Your Next Test

1. Accurate charting is crucial for patient safety and effective communication among healthcare providers.
2. Legal guidelines mandate that charting must be timely, precise, and comprehensive to avoid malpractice claims.
3. Electronic Health Records (EHRs) have become the standard for charting due to their efficiency and accessibility.
4. Confidentiality in charting is paramount; unauthorized access or disclosure can lead to legal repercussions.
5. Nurses must use standardized terminology and abbreviations approved by their institution when charting.

Review Questions

• Why is accurate charting important in nursing practice?
• What are the legal implications of improper or insufficient charting?
• How do Electronic Health Records (EHRs) enhance the process of charting?

Related terms

Electronic Health Records (EHRs): Digital version of a patient's paper chart, accessible in real-time by authorized users.

Confidentiality: The ethical principle that mandates keeping patient information private unless consent for disclosure is given.

Standardized Terminology: Consistent language approved by medical institutions used to ensure clear communication in documentation.