Charting Rules & Procedures

What is the required ink color for all written entries in chart records?

Black ink.

What methods are prohibited for correcting errors in chart records?

Liquid paper and ink erasers.

What should you do to correct an error in chart records?

Line through the mistake, initial the correction, and then make the correct entry.

What color ink should be used to record patient allergies?

Red ink.

Who is responsible for correcting their own errors in a chart?

Each staff member.

What should the NUC do if they find an uncorrected error made by another staff member?

Inform the staff member who made the mistake or notify the charge nurse if the staff member is unavailable.

Who is typically responsible for the destruction of records?

The Health Records Department.

What should you ensure before destroying a preliminary report?

The final version must match exactly, be proofread by a physician, and include the physician’s signature.

What must you always check before destroying or disposing of any records?

The hospital's policy on record destruction.

What should the NUC confirm before witnessing a signature on any document?

The hospital’s policy on witnessing.

If unsure about a procedure, who should you check with for guidance?

The charge nurse.