Undergraduate Program

General Documentation Guidelines

The medical record is a permanent legal document, which must contain thorough and sufficient information to identify the patient, their problems, their diagnosis and treatment. Accreditation and licensing agencies have specified documentation requirements. Several general documentation guidelines for ambulatory medical records are as follows:

• An individual medical record is established for each person receiving care.

• Medical record entries are documented at the time services are provided.

• Documentation should be objective, clear and concise. One cannot record critical remarks of the care provided by other providers.

• There should be a standard record format to the medical record. Only pre-approved forms should be filed in the medical record.

• All entries must include the date (month, day, year) and signature and title of the author.

• Entries must be legible and recorded in ink or type written.

• Use abbreviations and symbols only if their meaning are understood.

• The patient name and medical record number must appear on each page.

• Retain the originals of all reports.

• Document all patient encounters, including telephone contacts.

• Document patient education performed and record patient’s understanding of instructions.

• Indicate diagnostic work up was reviewed by initialing and dating each report. Document the plan of care for abnormal test results.

• To correct an error draw a single line through the entry, write "error", initial and date the correction.

• Add patient corrections to the medical record as an addendum, without change or deletion to the original entry. The addendum should be identified as such.