3.4.1 Overview

As a care provider, you will be documenting your observations as part of the client chart. Below you will see the information included in each of the medical records. When looking for information in the chart, it is helpful to be able to quickly locate these forms and understand the relevance to the client’s care.

Learning Objectives

At the end of this module, you will be able to:

  • Explain the importance of accurate and clear client documentation
  • Document client’s health effectively using appropriate charting methods
  • Complete an incident report
  • Report your client’s status verbally
  • Advocate for improvements to your client’s quality of life

Key Terms

When learning about observation and problem solving, it is essential to first look at the terminology to ensure that you understand everything clearly. These terms will be used throughout this book, so it is important to take the time to master them and practice your recall often.

  • medical record

Whenever these terms are first introduced in this chapter, they are bolded. However, if you need additional information about a term than what is provided here, you can research it in The Free Dictionary: Medical Dictionary.


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