Pt. Record Documentation Guidelines
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Authentication Change in Pt's Condition | Entries should be documented and signed(authenticated)by the auther.doucumentation must reflect any changes
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| Communication with Others | Any communication provided to the pt's family or DR. should be properly documented. ex:pt.change of condition on night shift.)Significant information related to the pt's care and treatment should be documented. ex: pt.condition,response to care,tx course,
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| Consistency | Document current observations,outcomes,& progress.>entries should be consistant doc.in record.>in doc. is contradictory, explanation should be included.
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| Continuous Documentation | Providers should not skip lines ro leave blanks when documenting in pt's records.>Do not generate a new form until the previous form is filled.ex:progress note sht.>If new form is started, the provider should cross out any remaining space on the previous
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| Objective Documentation | State facts about pt. care and treatmentINCORRECT:Pt. is pecularCORRECT:Pt. exhibits odd behavior
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| Referencing Other Patients | If other pt's are referenced in the record, do NOT document their names-reference their pt.number(s)only.
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| Pharmacy | Documentaion entries in the patient record are considered permanent and policies and procedures should be established to prevent falsification of and tampering with the record.
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| Physical Characteristics | Select white paper with permanent black printing to ensure readability of paper-base records.>Require providers to enter documentation using permanent black ink.>plain paper(not thermal paper)faxes are best if filed in the pt. record.File original documen
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| Specificity | Document specific information about pt. care and tx.INCORRECT:Eye exam is normalCORRECT:Eye exam reveals pupils equal,round,and reactive to light.
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