daily journal

NCM 107 Growth and

Development
SUBMITTED BY: DOMANTAY, UNA YVONNE E.
 Daily Journal
DOMANTAY, UNA YVONNE E. 9.14.22
BSN II-02

I can say how this day went well. The webinar about documentation
in MDH was very helpful for me, especially because it was confusing for
me to fill out those forms, and it can become handy for a 2nd-year student.
With no prior experience in the clinical area specifically in MDH, It’s
confusing how every single form is done, so I was beyond grateful that they
held an event something like this —something that will help us in the
clinical practice and guide us with what we will do.

There are some things I already knew about, but there are more things
tackled that were new to me. I didn’t know how critical these forms are, as
this is what will be our weapon when certain legal aspects or situations
arise. It is something that we can hold to when a patient complained or
questions about how the care was given, so the forms are not to be
considered as merely a paper but rather a significant object that we should
be serious about filling out.

A single or even a tiny mistake in filling out those forms can jeopardize
someone’s profession, as the medical record contains the overall health
history of the patient. As discussed, the medical record must be correctly
done and contain sufficient data to identify the patient, support the
diagnosis, justify the treatment, and accurate documentation of the results
of the treatment. The medical record has also several purposes and uses
such as to record facts about a patient’s health, especially the events
affecting the patient during his/her admission to the health care facility, to
document the course of illness and treatment, to communicate between
doctors and the health care team, for the continuing care of the patient, for
research and as well as a collection of health statistics,
 Daily Journal
DOMANTAY, UNA YVONNE E. 9.14.22
BSN II-02

In totality, the seminar was engaging and informative. It really upholds

its objective of providing quality medical records to the clients in MDH. As
this webinar has made me realize the importance of medical records, and it
also helped me navigate through the kinds of forms and apply what I have
learned. It aided a lot in the differentiation of forms, and it gave me a
glimpse of how a nurse in MDH does it. And at the end of the seminar, a
workshop was done and every BSN level was asked to fill out forms
according to a patient's case. All I can say is that it was a privilege to be in
that Zoom meeting as it gave me knowledge, skills, and experience.