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MODULE 6.0 PT CHART / DOCUMENTATION / COMMUNICATION

General Objective:

Upon completion of the module, the student will explain the importance of the patient's chart and demonstrate proper documentation procedures.

Specific Objectives:

6.1Locate the different sections of a patient chart and identify examples of Information found in each section

6.2Describe the legal and practical obligations involved in recordkeeping

6.3Accept and verify patient care orders

6.4Assess the patient’s leaning needs and educate them and the family concerning planned therapy and goals in understandable terms to achieve optimal therapeutic outcome

6.5Record therapy and results using conventional terminology as required in the health care setting and/or by regulatory agencies

6.6Communicate information regarding the patient’s clinical status to appropriate member of the health care team

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