Page 21 - Risk Reduction Series - Documentation Essentials (Part One)
P. 21
SVMIC Risk Reduction Series: Documentation Essentials
☐ All telephone communication, including evening and
weekend phone calls received after business hours
☐ All prescriptions (print or type to ensure legibility)
☐ Only approved abbreviations; the use of abbreviations
can be frequently misinterpreted and may result in harm
to patients. A list of accepted abbreviations and correct
dose designations is available on the Institute for Safe
Medication Practices (ISMP) website.
1
☐ Use of the metric system for medications
The Objective is to be Objective
What you document in the medical record should be first and
foremost objective. Any subsequent provider or third party
(insurance payer, accreditation agency, attorney, or juror) should
be able to clearly recognize elements of the medical record
identifying individual care. The best way to evidence individual
care is by using the patient’s own words wherever possible in
the documentation. If a patient describes her pain as feeling as
if someone stuck an icepick in her stomach, document that in
the narrative portion of the EHR in quotation marks as patient
described pain as, “feeling as if someone stuck an icepick in
stomach”. Also document the objective measurements, tests,
and other reports that led you to your conclusions.
Examples include the following:
• Imprecise: Patient remains stable.
1 www.ismp.org/tools/errorproneabbreviations.pdf
Page 21
