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Chp.5 (HIT-114)Shan.

Pt. Record Documentation Guidelines

Authentication Change in Pt's Condition Entries should be documented and signed(authenticated)by the auther.doucumentation must reflect any changes
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,
Consistency Document current observations,outcomes,& progress.>entries should be consistant doc.in record.>in doc. is contradictory, explanation should be included.
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
Objective Documentation State facts about pt. care and treatmentINCORRECT:Pt. is pecularCORRECT:Pt. exhibits odd behavior
Referencing Other Patients If other pt's are referenced in the record, do NOT document their names-reference their pt.number(s)only.
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.
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
Specificity Document specific information about pt. care and tx.INCORRECT:Eye exam is normalCORRECT:Eye exam reveals pupils equal,round,and reactive to light.