The document discusses various uses and guidelines for medical record documentation. It covers tracking patient progress, sharing information between providers, maintaining patient confidentiality, ensuring quality of care through audits, meeting requirements for insurance reimbursement, using records for research, and providing legal evidence. Key aspects that must be documented include assessments, nursing diagnoses, interventions, patient responses and outcomes. The document also reviews different charting styles like SOAP and problem-oriented documentation.

1. CHARTING