Patient Chart Documentation

Running head: PATIENT CHART DOCUMENTATION 1
Patient Chart Documentation
Student’s name
Institutional affiliation

PATIENT CHART DOCUMENTATION 2
Professional Practice I – Learning Plan Assignment – 5%
Patient chart documentation as a nurse
Patient chart documentation is a requisite in healthcare since it contains vital roles and
information of every member. Notably, in nursing, the patient chart documentation assists in
developing the continuity of quality patient’s care, safeguarding the nurses from malpractice,
justifying the clinical reimbursement, and fostering communication between the providers in the
health care. The patient chart documentation in healthcare provides the nurses with a record of the
performances done concerning the patient in the past. The chart mainly includes prescriptions,
procedures, results of the test in the healthcare and all the interactions that the patient has undergone
with health care professionals and doctors. Medical conditions, past surgeries, and hospitalization are
also documented to provide essential information that a nurse may require to understand the
occurrences of the patient and define the problem.
Some of the steps that get included in the patient chart documentation include registration,
development of financial responsibility, check out and check in of the patient, checking for billing as
well as coding compliance. Transmitting and preparing claims, monitoring the adjudication payer,
creating patients bills and statements, assigning payments and arranging collections to the patients
(Blair, & Smith, 2012). Nurses check doctors’ orders from the written request by a doctor or entering
into the patient's chart in the direction of the doctor. However, formal orders get valued for
instructive the allocation of a specialist in a specific setting. Patients are identified either through the
particular record number of outpatient, inpatient or emergency patients.

PATIENT CHART DOCUMENTATION 3
Self- Assessment
Areas of Strength Practice Concept Practice Component
1. As a nurse, i can prepare patient
documentation following the entire
procedure of documenting. According to
a rule in the nursing specialty, I
understand that if I have not recorded the
information, then the whole process is not
prepared. I can ensure that the
documentation provides consistent and
safe quality health care to the patient.
I also have the competence to use the
technology software that is used to
improve health care and mitigate the
diseases among the patients. Am also
competent in using the technology to
handle the billing methods and track the
procedures in the hospital (Blair, & Smith,
2012).
Caring and
competency
Documentation and
technology
2. As a nurse, I understand that a caring
relationship is a vital segment that
facilitates the health and also the process
of healing in a patient by engaging the
specific requirements of the patient. I can
Caring and
connectedness
Caring Relationships

Confidentiality