Learning Objectives
In this section, the student will:
- Explain the importance of the use of electronic medical records (EMR) and shared information systems
- Describe HIPAA regulations
- Identify appropriate techniques to document client encounters
- Describe the importance of adhering to confidentiality in all areas of communication
- Demonstrate professional documentation
Resources
- Benefits of Electronic Health Records (EHRs); from HealthIT.gov
- HIPAA for Professionals; from the US Department of Health & Human Services
- Guidelines for Medical Record Documentation; from the National Committee for Quality Assurance
- American Nurses Association Position Statement on Privacy amd Confidentiality; from the American Nurses Association
- University of Washington School of Pharmacy Primer on Writing SOAP Notes; from the University of Washington
- The Value and Importance of Health Information Privacy; from Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research
