Week 10

Documentation & Medical Record

Objectives:

 Student should able to maintain a medical record

 Student able to list the components of traditional medical record

References:

Chapter 3; Quality, patient safety,communication and Recordkeeping.

Kacmarek R, et al. Egan’s Fundamental of Respiratory Care 11th Edition.

Tasks:

1. Vital signs/ Breadth sounds/ oxygen saturation

2. Types of therapy/Test
3. Medication administered
4. Patient response
Identifies the patient’s medical record
5. Match the name/attending physicians name/room no.
6. Identify the cross section for documentation
Appropriate documents in medical record
7. Date/time
8. Patient assessment data
9. Procedures/interventions/ medications administered
10.Return the medical record to its proper place
Note:

 This checklist will not come as a sperate one

 Buuuut my advice is to know the steps, so if any doctor asks you. ‫ال‬
‫تتورطو‬