Documentation Best Practices
Jun 01, 2013
Write it Right
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. If appropriate, note the reason for diverging from standard practice
- Record the risk-benefit analysis of important decision.
- 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 (if they are specific to the patient).
- Document patient education, instructions
- In addition to the patient, consider the “audiences” that may have access to patient records such as insurance companies, regulatory agencies.
- 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 review what is being copied to avoid perpetuation of information that is no longer accurate or relevant.
- Notes should be recorded contemporaneously with medical care; a long time lapse before entry diminishes credibility.
- Late entries are appropriate for information that is missing or incompletely documented.
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 of discordance may lead to loss of trust in 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.
- Paper: draw a line through incorrect entry with initials and the date. Provide corrected information.
- EHR: 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.
- Do not make an addendum in anticipation of a claim or legal action because it may:
- be characterized as an attempt to falsify or change the record of fact
- appear to be “self-serving” rather than providing information that is needed for patient care
- seem defensive, may not contribute to the care of the patient, and should be avoided
Published in June of 2013, Revised January 2021
This page is an excerpt of a full issue of Insight.CME: The Massachusetts Board of Registration in Medicine has endorsed each complete issue of Insights or 30-minutes of podcast episodes as suitable for 0.5 hours of Risk Management Category 1 Study in Massachusetts. You should keep track of these credits the same way you track your Category 2 credits.
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