Charting Rules & Procedures

To ensure that chart records meet legally accepted standards, certain rules and procedures must be followed:

  1. Ink Color

    • All written entries must be made in black ink.

  2. Corrections

    • Liquid paper or ink erasers are not permitted.

    • To correct an error:

      1. Line through the mistake,

      2. Initial the correction.

      3. Then, make the correct entry (e.g., lab aware, JM x-ray aware).

  3. Red Ink

    • Use red ink specifically for:

      • Recording patient allergies. - Some hospitals do not allow this any more. For course purposes use RED ink for all allergies 

  4. Error Correction Responsibilities

    • Each staff member is responsible for correcting their own errors in the chart.

    • NUC (Nursing Unit Clerk) should not correct others' errors but should inform the staff member who made the mistake.

    • If the staff member is unavailable, the NUC should inform the charge nurse about any uncorrected errors they find.

Retention and Destruction of Records

  1. Destruction of Records

    • Generally, the NUC is not responsible for destroying records; this is handled by the Health Records Department.

    • The exception: Destruction of a preliminary report after the final version is received. Be sure the final version matches exactly, has been proofread by a physician, and includes the physician’s signature.

    • Never destroy a report that includes a physician’s signature.

  2. Know the Hospital's Policy

    • Before destroying or disposing of any records, forms, memos, or meeting minutes, always check the hospital's policy on record destruction.

    • If you're unsure, ask the charge nurse for guidance.

Witnessing Documents

  1. Witnessing Signatures

    • The NUC should never witness a signature on any document without first confirming the hospital’s policy on witnessing.

    • Policies regarding witnessing signatures can vary between hospitals, so it is essential to understand your hospital’s specific guidelines.

  2. Policy

    • If you're unsure about the correct procedure, always check with the charge nurse.