What process is used for documenting a patient's medical history and treatment progress?

Patient charting is the process designed specifically for documenting a patient's medical history and treatment progress. It involves the systematic recording of patient information such as past medical history, symptoms, treatments administered, responses to treatment, and any changes in condition over time. This documentation is essential for creating a continuous care plan, allowing healthcare providers to evaluate the effectiveness of treatments, coordinate care among different providers, and ensure compliance with clinical standards.

The patient chart serves as a legal document that can be referenced in future medical encounters and is crucial for effective communication between members of the healthcare team. Maintaining accurate and up-to-date patient charts is also vital for fulfilling regulatory requirements and providing evidence-based care.

While clinical audits focus on evaluating the quality and efficiency of medical care and case management pertains to coordinating patient care among various providers, patient charting specifically hones in on the detailed documentation of individual patient encounters and progress over time. Health informatics involves the systematic collection and analysis of health data but does not exclusively refer to the direct documentation of individual patient histories and treatments.