What it means
It holds the history, assessments, orders, medications, test results, care given and the client's responses, usually as an electronic health record (EHR). It is how the team communicates, the basis for billing and quality review, and a legal document that can be used in court. The client has a right to see it, and its privacy is protected by law (in the US, HIPAA).
For the nurse
Chart promptly, accurately and objectively, only for care you gave or saw, and never before it happens. Look only at the records of clients you are caring for, and log out when you leave a computer.
At a glance
| Also written | health records |
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Related terms
informed consent
A person's agreement to a treatment or procedure, given freely after the risks, benefits and other choices have been explained to them.
handoff report
The passing of information and responsibility for a client's care from one nurse or team to another.