Question

Describe why the following guidelines for vital when communicating in a medical record (documenting time, using abbreviations and symbols, punctuation and spelling)

Answer 1

Time will assist to know when the patient was seen and the how they were at that particular time
Using abbreviations and symbols- this is used so as to save time and in the medical records they have their own language that they use to encode
Punctuation and spelling- Is key because this will help another doctor or pharmacist to be able to understand the patients file in case of a referral