How to Write a Medical Chart

A medical chart provides communication among the health care professionals about a patient's health and care experience. The purpose of this chart is to serve as a medical and legal record, according to eNotes. As a medical record, the chart provides information on the patient's health, including admission, treatments and responses. As a legal record, the medical chart provides evidence of the patient's care experience. Health care professionals must enter this information clearly and concisely when writing in the medical chart.

Instructions

• 1

  Write the date and time on all patient encounters. This includes admission, medication, surgery and treatments.

• 2

  Write the patient's full name. Include any other identifiers such as the patient's date of birth or a medical record number.

• 3

  Write the medical record in chronological order. Do not leave out any information that is pertinent to the patient's care.

• 4

  Record any statements made by the patient or others in quotes. Always use the current time and date with documentation.

• 5

  Document any occurrences that may affect the patient. This evidence may be necessary in a court case. The court considers information not documented as questionable.

• 6

  Write objectively, instead of subjectively. Explain if the patient was hostile toward the physician or staff without using derogatory or judgmental language.

• 7

  Cross out any errors. Draw one line through the word and write the correct word. Insert your name and the current date after you made the proper correction.