The topic of medical record documentation is about as exciting as watching paint dry. However, time after time we find that missing, incomplete, or illegible documentation seriously impedes safe patient care and the defense of malpractice claims, even when care was appropriate.  The medical record is a legal document and, as such, demonstrates adherence to state and federal regulations, evidence-based practice guidelines as promulgated by professional organizations, and it provides the information necessary to support billing and reimbursement. It is also the provider’s greatest defense in the event of a claim by providing a contemporaneously written record of the “what, when, why and hows” of the care provided. 

The documentation elements that often lead to unanticipated outcomes, medical errors, and claims include:

ü      Missing documentation that leads to failure to diagnose, such as after hours telephone calls, a record of direct provider-to-provider communication, adherence to or reasons for not following evidence-based practice guidelines (e.g. rationale for choosing one particular course of action over another), and follow-up of ordered tests and consultations

ü      Unsafe medication documentation practices, such as utilization of trailing zeros and not utilizing leading zeros, or the use of abbreviations that lead to medical errors

ü      Illegibility

Documentation do’s and don’ts

ü      Use permanent ink, not soft felt pens or lead pencils.

ü      Write legibly; print if your handwriting is indecipherable. The use of encounter forms, checklists, flow-sheets, and computer-assisted documentation for high-volume activities can save time and may also reduce communication problems and errors caused by illegible handwriting.

ü      Date, time and sign all entries, including your professional designation. Use precise time whenever possible. Precision contributes to an impression of thoroughness.

ü      Each entry should be in chronological order. Late entries and addendums should be identified as such. Document the date and time of all added note entries.

ü      Use only abbreviations approved by the facilities in which you have privileges and consider adopting these abbreviations at your practice site (for the complete Joint Commission list of “Do Not Use” documentation go to http://www.jointcommission.org/PatientSafety/DoNotUseList/).

ü      When utilizing progress note style forms, do not leave blank lines between entries.

ü      Do not erase, use “whiteout” or obliterate a notation. Incorrect entries should be corrected by drawing a single straight line through the mistake, then write “mistaken entry” above or next to it. Include your initials and the date of the correction.