Different types of medical record documentation

Assignment Purpose:

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Gain an understanding about different types of medical record documentation and associated legal issues of an EHR

Assignment Description

Step One: Select three types of medical record documentation that you would expect to see in an EHR (e.g. H&P, operative report, labs, nursing documentation, discharge summary, etc.).

Step Two: Locate an article, legal case, report, white paper or other resources that discusses a legal issue associated with the types of documentation that you selected. (NOTE: you may have to locate more than one article to cover all three types of documentation.)

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Instructor’s Comment

Instructors Comments:Hi Irene, Qualitative Feedback: You completed this assignment in a detailed and complete manner. You included a comparison of research in relation to methodology in a focused manner with supporting details. A comparison of research in relation to goals and data collection is well developed with supporting details included. Number of required resources is met; APA format intact. Quantitative Feedback: please see the rubric.

Irene

Instructor's Comments:Hi Irene, Your initial post answered the question and provoked further discussion. You included information and rationale to support your discussion. Relevant citations were included.

Irene2

nstructor's Comments:Hi Irene, Your initial post was detailed and included relevant information. You provided insight into our discussions. You included information and rationale to support your discussion. Appropriate citations were included.

Irene 4

Instructor's Comments:Hi Irene, Thank you! Your post was comprehensive. You answered the question with detail and provided specific examples. Sources were relevant and recent.

Irene 4

Instructor's Comments:Hi Irene, Thank you for your response! Your ideas were presented in a logical manner. Details and examples were provided to support your thoughts. Relevant resources grounded your ideas in the literature.