Explain the purpose, parts, and information found in the medical record.
Explanation should include
- contents
- permission to access
- legal implications of documentation
- electronic medical records (EMRs)
- 24-hour clock.
Process/Skill Questions:
- Who has ownership of patient/client records?
- What are the components of the medical record?
- How is the care plan used?
- How do you correct an error made in medical records?