Page 17 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

☐ A one-screen summary which includes active problems,
medications, allergies, and progress notes, as well as an
organized view of test results or progress notes, should be

available.

☐ Completed office notes should be electronically signed and
locked so they cannot be modified or revised.

☐ Discontinued medications should be easily identified in the
EHR and should not “disappear” once discontinued.

Unique to Paper Charts

☐ There should be a separate record for each patient.

☐ All papers should be permanently affixed in the record.

☐ Patient identification should be on the front and back of
every page containing patient information.

☐ For paper records in which handwritten notations or
signatures are found, maintain a signature log or card that
identifies the name and title associated with initials used in

the medical record.

☐ Legibility is a must! Careful diagnosis and a good
treatment plan are useless if the written orders are illegible.
Remember that a jury in a medical malpractice action will

equate hurried and sloppy documentation with sloppy
care.

The Medical Record in the Office Setting Should

Include

☐ Demographic information which includes:

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