Overview
Module
9 focuses on the essentials of documentation.
The module provides a discussion of the medical record and
tips for accurately documenting a well-child visit. Specific
documentation requirements for each component of the health
visit are also included.
Guiding Questions
Users who complete the Documentation module should be able to answer the following questions:
- Why is careful documentation a critical aspect of quality health care?
- How does documentation benefit health care providers, families, and children?
- What are some general guidelines for ensuring proper documentation?
- Why is the medical record so important in a mobile society?
- How are specific components of a health visit documented in the medical record?
| Getting the Most from this Module: |
Documentation is in the details. After reading the general guidelines and tips, be sure to review the practical steps for documenting each major component of the well-child visit: history, exam, screenings, lab tests, immunizations, and guidance. |
