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5.5 Documentation

Understanding the types of drugs/medications and their purpose, function, and effects on the body.

Critical Work Functions

    5.5.1 Maintain accurate and objective records.
      5.5.2 Submit records to appropriate sources in a timely fashion.
        5.5.3 Maintain standards of confidentiality and ethical practice.
          5.5.4 Maintain currency with appropriate documentation systems.
            5.5.5 Comply with policies and requirements for documentation and record keeping.
              5.5.6 Demonstrate an understanding of the role of the health care provider in medication delivery.
              • Information requirements
              • Signature requirements
              • Approvals
              5.5.7 Completing forms
              • Appropriate form selection
              • Time requirements
              • Accuracy
              • Completeness
              5.5.8 Maintaining Records
              • Organizational requirements
              • Timeliness
              • Accessibility
              5.5.9 Confidentiality
              • Legal requirements
              • Medical terminology