ABSTRACT
The information contained in this chapter comes directly from an actual medical record obtained via the patient’s consent. Identifying information has either been changed to fictitious information or otherwise redacted. The elderly patient sustained a fall resulting in a fracture of the intertrochanteric section of the femur (fracture of the hip). The patient’s course of treatment will be followed by examining the several parts of the medical record in hopes of gaining a better understanding of what information should be documented in the chart and what the chart tells us. It should also be noted that two legal registered nurse consultants were interviewed for their knowledge and insight as it pertains to the content of the medical record.
