Page 15 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 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 payer.

 Documents that do not constitute the official medical record

should be kept separate from the medical record and

restricted from disclosure. Examples include incident reports,
peer review documents, privileged documents and

correspondence with SVMIC.

 Original medical records should not be removed from the

office.

 Use only standard abbreviations so entries are not
misunderstood.

 Accuracy is vital. A misplaced decimal point or inadvertent

use of a wrong term has precipitated medical disaster.

 The record should contain only facts and clinical judgment.

Remarks on a patient’s personal characteristics are not

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