Page 15 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

General Documentation Guidelines

☐ Records should be organized thoughtfully and efficiently
so that the medical and office staff can quickly locate
information in any given record (i.e. grouping all progress
notes together, all lab results together, consults together,

etc.).

☐ Records should be complete. This does not mean
documenting everything. Poorly written, voluminous

records may actually increase liability exposure. The key is
to be objective and concise.

☐ Notes should be dictated, typed, or legibly written in an
organized format (i.e. SOAP).

☐ Entries should appear in chronological order.

☐ All entries should be timed and dated and include
authentication with a minimum of the first initial and last
name.

☐ All boxes and checklists must be completed to show they
were reviewed.

☐ Records should be prepared as contemporaneously with
treatment as possible in order to avoid confusion and help
ensure validity—within 24-48 hours is recommended. The

practice should have safeguards in place to ensure office
notes are completed prior to submitting charges to the

payor.

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