Medical Charting Policy & Procedures

Charting is the process of documenting patient care in a medical record. Because patient records are legal documents, there are specific policies and procedures that clinicians must follow when charting.

Legibility

• All handwritten entries require legibility to provide continuity of care.

Authentication

• Entries are authenticated, or signed, at the time of treatment by the caregiver.

Date and Time

• All patient documentation is accompanied by a date and time. This is written for paper medical records, or digitally stamped for electronic records. It is illegal to pre-date or back-date entries.

Abbreviations

• Clinicians can use only organization-approved abbreviations, acronyms and symbols when charting.

Errors

• Errors are not eliminated from patient records. In handwritten instances, a single line should strike through the error, with “error” written along the line, completed with the clinician’s initials and date.

Timeliness and Completeness

• Documentation is completed as the patient is treated. Reports providing current treatment information, like the history and physical, are completed within 24 to 48 hours of the patient admission. Organizational policies and procedures, and in some cases regulations and state law, create medical record completion requirements. In many cases, patient medical records must contain all completed reports, documentation and signatures within 30 days from when the patient was treated.