Identify the chart components related to electronic and paper records.
DefinitionIdentification should ensure that the following types of information is included:
- Past medical records
- Clinical data
- Progress notes
- Diagnostic information
- Lab results
- What documentary evidence does the medical chart include?
- How does a properly-assembled chart protect the legal and safety interests of the patient?
- How does a properly-assembled chart serve as the basis of patient care?
- What happens if information is omitted from a patient chart?
- What are the advantages and disadvantages of paper records vs. computer-based records?
Related Standards of Learning
The student will read, interpret, analyze, and evaluate a variety of nonfiction texts including employment documents and technical writing.
- Apply information from texts to clarify understanding of concepts.
- Read and correctly interpret an application for employment, workplace documents, or an application for college admission.
- Analyze technical writing for clarity.
- Paraphrase and synthesize ideas within and between texts.
- Draw conclusions and make inferences on explicit and implied information using textual support.
- Analyze multiple texts addressing the same topic to determine how authors reach similar or different conclusions.
- Analyze false premises, claims, counterclaims, and other evidence in persuasive writing.
- Recognize and analyze use of ambiguity, contradiction, paradox, irony, sarcasm, overstatement, and understatement in text.
- Generate and respond logically to literal, inferential, evaluative, synthesizing, and critical thinking questions about the text(s).