Medical charting is the process used to keep track of all interactions with patients in a clinical environment. Every patient has a medical chart in which a wide variety of information is recorded by the care providers who interact with the patient. Since many people see multiple doctors, it is not uncommon for patients to have multiple medical charts. In some countries, the maintenance of electronic health records has been proposed to prevent this, ensuring that a patient’s entire medical history can be readily accessed.
The information in a medical chart starts with the basics: the patient’s name, date of birth, and other simple demographic information which is relevant to medical care, such as marital status, obstetrical history, and so forth. The front page of a medical chart usually provides this information, allowing a care provider a quick overview of the patient’s basic characteristics. Conventionally, medical charts are kept in folders or binders, with pages organized in chronological order.
When someone engages in medical charting, additional records are added to the medical chart. Whenever a patient presents with a problem, the primary complaint is recorded, along with the outcome of examinations, any tests ordered, and treatments used. If medications are prescribed, the prescription is recorded in the medical chart, along with the patient’s response to the medication. Likewise, the medical chart includes records of surgeries and other medical procedures, along with observations from caregivers.
Medical charting is critical for keeping track of the medical history of a patient. Caregivers can use a medical chart to identify allergies, risk factors for various diseases, and other issues which might be immediately relevant to treatment. The history in the medical chart can also be evaluated when establishing patient plans and discussing options with the patient. Medical charting is also used as a basis for the provision of insurance benefits and billing.
For hospitalized patients, medical charting provides a medium of communication for caregivers. Nurses record vital signs and note when medications were administered, along with other information of note, while doctors record the outcome of patient meetings and procedures performed on the patient. The medical chart also includes signed consent forms and other legal documents pertaining to patient care.
Medical charts are also legal documents. Every piece of information in a medical chart can be used in a legal case, ranging from a malpractice suit against a doctor to a suit against a pharmaceutical company for a faulty drug. For this reason, people receive special training in medical charting during their medical training, learning a standardized format for charting and being informed about the legal ramifications of charting.
Many medical professionals do not relish medical charting, since it needs to be performed meticulously and very carefully to ensure that all relevant data is recorded. Missing a step in medical charting can be legally dangerous, and potentially bad for the patient. For example, if a nurse administers a medication and fails to record it, another nurse may note that the medication has been ordered but not administered according to the chart, and the medication would be given again, putting the patient at risk.