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Medical Documentation Tips

The medical record is a chronological document that proves medical care. According to the Family PACT, "If it's not in the chart it didn't happen." The doctor is legally bound to document her treatment of every patient that she examines. This protects both the patient and the doctor and offers proof of services rendered for payment.

  1. Patient's Identification

    • The patient's name and identification number should be on each page in the patient's chart to safeguard against misfiling, which could lead to a patient being treated based on another patient's diagnosis.

    Time & Date

    • Write the date and time of each visit. This includes initialing and dating labs when they are reviewed. Time and date are important not only for treatment and medication orders but also for insurance reasons. The doctor has documented how long the visit lasted. The amount of time spent with a patient could make the difference of which code to use at billing time, as the CPT codes account for extended periods of treatment.

    Legible Writing

    • Information in the chart should be legible to someone other than the author. The medical chart is a legal document and should the need arise--in the case of a malpractice suit--it should be easily read by someone other than the caregiver. On a similar note, Princeton Insurance reports that only approved standard abbreviations should be used.

    Patient Contact

    • Document, using black or blue ink, each visit with the patient and what took place during the visit. This includes telephone conversations, follow-up instructions given, patient education given---whatever took place during the visit that could potentially have an effect on the patient's care needs to be included.

    Allergies

    • Any known allergies should be immediately visible on the chart. Highlight to make it noticeable to avoid allergic reactions to medications, food or care.

    Inappropriate Content

    • Some things are best left out of the chart if they don't affect the patient's health. According to Princeton Insurance, incident reports, criticism of another doctor's work or diagnosis, disagreements with patient or patient's family should not be in the medical records.

    Pre-printed Forms

    • The use of pre-printed forms will save time and increase accuracy. Family PACT reports that "additional advantages of pre-printed forms are that they: prompt the clinician for important elements for each visit, reduce the writing required, and improve legibility."

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