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Documentation Best Practices

Protect your patients, your team and yourself by following these guidelines when writing your clinical notes.

Entries should be...


  • Document your clinical rationale at critical decision points, e.g., a new finding or change in the patient’s condition
  • Record the risk-benefit analysis of important decisions
  • Don’t chart a symptom without documenting your response response should meet the standard of care
  • Describe actions of the patient rather than labeling behavior: “pt has not kept scheduled appointment with GI” rather than “pt is difficult and non-compliant”
  • Avoid comments that could be viewed as disrespectful or prejudicial, e.g., attention seeking, histrionic, dramatic
  • Include socioeconomic information only if relevant to care
  • Document communication with other clinicians
  • Document patient education, instructions
  • Consider the “audiences” that may have access to patient records, e.g., insurance companies, regulatory agencies
    • remember, patients often request copies of their medical records, particularly if there has been a bad outcome
  • Avoid hearsay: do not record what someone else said, heard, felt, or smelled unless information is critical; use quotations and attribute remarks accordingly


  • Avoid vague terms; e.g., write “9 x 5 x 1 cm wound” rather than“medium wound”
  • Beware copying and pasting in electronic medical records


  • Notes should be recorded contemporaneously with medical care; a long time lapse before entry diminishes credibility

Avoid chart wars

  • Do not joust in the record
  • Avoid criticizing other staff—current or former caregivers
  • Be aware that all relevant facts about prior care may not be available
  • Patient’s perceptions of care may be inaccurate
  • Conflicting chart entries undermine your credibility
  • Patient awareness will lead to loss of trust in hospital/caregivers
  • Use appropriate chain of command, not medical record, to address conflicts with other providers or administration
  • Do not prompt patients to consider litigation
  • Do not make assumptions; if something is not clear, get clarification
  • Do not amend or alter entries in the record without using the appropriate process



  • Late entries are appropriate for information that is missingor incompletely documented 
  • Mark with time/date of late entry, refer to original event
  • Do not make an addendum in anticipation of a claim or legal action
    • may be characterized as an attempt to falsify or change the record of fact
    • may appear to be “self-serving” rather than providing information that is needed for patient care
    • appears defensive, does not contribute to the care of the patient, and should be avoided


  • Paper: draw a line through incorrect entry with initials and the date. Provide corrected information.
  • EMR: add a clearly marked addendum to the original entry with the corrected information state the reason for the correction
    • do not delete or make original information inaccessible

June 6, 2013
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