Question

Think about the role you play in charting on a patient’s health record. What is your typical routine for charting, does your process leave room for error, why/why not? What should/could you change about your process? How would you handle a patient’s request to change data that you have entered into their health record?

Answer 1

Answer: As the assessment is being done, at an instant I record all the signs and symptoms to the chart. It is better to note down the things i.e. condition as well as notifications on the patient's health chart because it will reduce the chances of error. Many times error occurs due to the pending information, or the records maintained by the nurse not at the particular time. But to avoid any kind of error, as soon as the assessment is done, report should be completed. The information such as medications, procedures, results of diagnostic tests and all interactions with doctors and other healthcare professionals should be recorded in the chart instantly. If the patient request to change data that has been entered into their health record then physician has the right to determine if the change will be made or not. It is because of physician knows well about the condition of the patient A patient has the right to request any changes to his or her medical record.