CRICO CRICO home

CRICO MDs ONLY: Register to access your facesheet, and more.

Advanced Search

  • Topic
  • Specialty
  • Content Type

RESET SEARCH CRITERIA

Insight CME

Also Related

< Back To Patient Safety
0 dislikes

< Hide

Comments For

Write it Right

0 comments

< Shrink

Add Your Voice

All comments are posted anonymously. Your comment will be attributed to: "Anonymous user."

post comment

Delete

Are you sure you want to delete this comment?

Documentation Best Practices

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

Entries should be...

...OBJECTIVE

  • 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

...SPECIFIC

  • 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

...TIMELY

  • 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

 

Addenda

  • 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

Corrections

  • 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
0 dislikes

< Back To Patient Safety