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Discharge ADSL Procedure for Speech Language PathologistsContents Internal Discharge Procedures ......................................................................................................................
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What is clinical record keeping in?
Clinical record keeping is the practice of maintaining accurate and detailed records of patient health information and medical treatment.
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Healthcare professionals and medical institutions are required to file clinical record keeping.
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Clinical record keeping forms are typically filled out manually or electronically, providing detailed information about the patient's medical history, treatment, and progress.
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The purpose of clinical record keeping is to ensure accurate documentation of patient care, enable continuity of care, support decision-making, and comply with legal and regulatory requirements.
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Clinical record keeping must include patient demographics, medical history, diagnostic test results, treatment plans, medications administered, and progress notes.
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