Medical Records: Documentation Rules & Classroom Expectations

Documentation Foundation

  • The fundamental rule: If it isn’t documented, it didn’t happen!
  • Do not leave blanks; be accurate; include time, date, and signature on all entries.
  • Every record should clearly show who accessed the chart and who recorded the information.
  • Unclear, incomplete, or unclear documentation leads to grave consequences, including:
    • Wrong treatment decisions
    • Unnecessary, expensive diagnostic studies
    • Unclear communication among consultants and referring physicians, which can affect follow-up evaluations and treatment plans
    • Inaccurate information regarding patient care
    • Poor patient care
    • Risk to the physician’s license
    • Lost revenue and reimbursement
    • Inappropriate billing that could lead to fraud charges
  • Blank spaces on charts create ambiguity and can have legal ramifications; a patient who sues has a stronger case if treatment wasn’t documented.
  • Write down information accurately in real time.
  • Inaccurate or misleading documentation is unethical and can harm patients.

- A record of who accessed the chart and recorded information must be accurate.

Classroom Expectations

  • Maintain accurate and complete notes in work in this class.
  • Blank spaces are not allowed on any work in this class.
  • If appropriate, write N/A, but don’t leave it blank.
  • All documentation in the course will be graded for accuracy, completeness, and professionalism.

- Everything you document in this class will include your FULL name and date.

Prioritize Legibility and Ink Standards

  • PRIORITIZE LEGIBILITY; use a BLUE or BLACK PEN.
  • NEVER CHANGE WHAT YOU’VE CHARTED; others must be able to read your documentation without difficulty.
  • Medical Records can be used in legal proceedings; for that reason, use only blue or black ink.
  • Once an entry is made, it is permanent; health records are legal documents, so never alter or change what you’ve charted.
  • If there is an error, follow the corrections policy outlined in your facility’s policy.
  • Most facilities will accept a single-line correction after you correct the mistake and label it with the time, date, and your initials.
  • NEVER erase a mistake with correction fluid or by blacking it out with ink.
  • When you use abbreviations, use the standard abbreviations for your employer; avoid obscure or colloquial abbreviations.
  • BE OBJECTIVE; your work must be legible and take your time.
  • In this class, you may use pencil if you prefer.
  • In your group lab booklet, any changes or errors will follow the proper procedure for medical records.
  • Draw a single line through what is incorrect.
    • Neatly write the correction and reason.
    • Date and initial the change.
  • You will follow this rule when using any abbreviations.
  • Do not write down opinions as facts; use quotation marks to indicate an opinion and attribute remarks to the correct person.
  • You must properly document any opinion.

- Your group SOAP notes will be objective.

Handling Errors in Entries

  • Draw a line through the entry (a thin pen line); ensure that the inaccurate information remains legible.
  • Initial and date the entry.
  • State the reason for the error (e.g., write in the margin or above the note if there is room).
  • Document the correct information.
  • If the error is in a narrative note, you may need to enter the corrected information on the next available line/space, documenting the current date and time and referring back to the incorrect entry.

- Do not obliterate or alter the original entry by blacking out with marker, using white-out, or writing over the entry.

Omissions and Late Entries

  • When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record.
  • Identify the new entry as a "late entry".
  • Enter the current date and time; do not give the appearance that the entry was made on a previous date or earlier time.
  • Identify or refer to the date and incident for which the late entry is written.
  • If the late entry documents an omission, validate the source of additional information as much as possible (e.g., use supporting documentation on other facility worksheets or forms).
  • When using late entries, document as soon as possible.

- There is no strict time limit for late entries, but the more time that passes, the less reliable the entry becomes.

Addendums and Additional Information

  • Document the current date and time.
  • Write "addendum" and state the reason for the addendum, referring to the original entry.
  • Identify any sources of information used to support the addendum.

- Complete the addendum as soon after the original note as possible.

Reference / Source

  • Source reference: https://www.ncbi.nlm.nih.gov/books/nbk48/2263/
  • This material provides foundational concepts for medical record documentation and addenda practices.