CNA TestPrep: CNA - Medical Records/Charting Quiz

When a patient is admitted to the hospital or any healthcare facility a medical record is established. A medical record is the place that all disciplines document and the collective place that information can be located about a patient's demographics, history, current complaints, illnesses, treatment and response to treatment. It includes documentation from the attending physician, consulted practitioners, nursing, therapy (Speech/OT/PT), the social worker, dietician, laboratory and any other professional involved in the care of the patient. It serves as a confidential and legal document and there are policies and procedures for documenting within the medical record.