After a medical assistant has notified his or her supervisor and the physician of an error in patient care, her or she should then: document the error in the medical record.
An individual patient's medical record identifies them and provides details about their medical history with a specific provider. The patient is correctly identified in both the health record and any electronic version of the conventional paper files.
Other healthcare professionals are typically taken into consideration when writing the material. When patients read these notes, it may cause them to become confused and feel harmed. For instance, some abbreviations, such those for shortness of breath, are the same as those for profanities, and taking "time out" to adhere to a surgical safety protocol may be misinterpreted as a method of child discipline.
Informed care can be given since health care professionals can learn about a patient's medical history through their medical record.
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