Medical Records and Documentation
2 Contact Hours
Written By: B. Moore, HCRM RN
Prepared Especially For:

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This Continuing Education course will provide the Healthcare Provider with two (2) Contact Hours of Continuing Education units (2 CEUs) that may be used for their license or certification requirement for continuing education. 

This course will cover such issues as various documentation formats and principles of various forms of documentation.  Common mistakes in charting to avoid will be addressed.  Recommendations will be presented to assist in quality medical record keeping and documentation. 




The goal of this training program is to help the Healthcare Provider to document properly.  This program will help to identify preventable errors of documentation and describe how to document correctly in order to provide a safer health care environment for the patient. 


After you study the information presented here, you will be able to:

        Identify avoidable medical documentation errors.


Provide constructive changes to prevent such errors.


Correct medical documentation errors or change a record for the right reason and in the right way.


Provide a safer health care environment for the patient by documenting proactively.



Satisfactory completion of this two hour Medical Record and Documentation course will earn the participant two Contact Hours of Continuing Education.  The participant must successfully pass the post course written examination with a minimum score of 80% and complete the post course evaluation form.  A course completion certificate will be issued after all course completion requirements are met.

Medical Records and Documentation


Medical records are legal documents, whether in written form or as a computer-generated form. Medical Records provide proof of the care patients receive including the response to that care.  More recently, the Medical Record is referred to as the Clinical Record consisting of all of the contributions from each health care provider providing care to that patient.  To protect you legally you must follow the established rules of documentation and know how to document properly. 


The development of specific medical documentation guidelines falls primarily to professional organizations such as the American Nurses Association (ANA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).  Other rules are governed by such agencies as: the Health Care Financing Administration (HCFA), the Agency for Healthcare Administration (AHCA), Medicare, and Medicaid.  The regulations require medical records to be kept for every patient and these records must contain specific information to justify the diagnosis and treatment provided.


Every medical person (doctors, nurses, therapists, etc) adds their own documentation information within the Medical Record.  Medical Records provides a means of continued communication for all medical care providers that render any care or treatment to the patient. 


Patient data is used for claims payment, utilization review, underwriting and coverage decisions, and litigation.  Health care providers use the data for research, to collect reimbursement, manage diagnosis and treatment, conduct quality assurance, and monitor other providers.


The Medical Record generally contains a Patient Face Sheet describing the patient such as the patientís true name, address, age, social security number, physician, diagnosis, and the name of patientís insurance carrier.  It also contains the next of kin. The Medical Record generally has Physician Orders and Physician Progress Notes that the doctor documents after reviewing the chart and the patient.  It will also contain the Nursing Record that may include the Intake and Output Record, vital signs documentation, and the Nurseís Progress Notes.  Frequently other sections may include; the Medication Record, Xray Record, Laboratory Record, Physical Therapy Record, the Surgical Record and any other section for any other referred specialties.          


Medical Records that are poorly maintained, incomplete, inaccurate, illegible or altered create doubt regarding the treatment given to the patient and can cause a jury to find the health care provider lliable.  The idea behind documentation is to provide communication for the patientís benefit, your protection, and the protection of your facility.  There is an old saying in the medical industry, "If it was not documentedÖit was not done".  This statement is so very true and therefore to verify what you as a healthcare provider have performed, you must always describe and document your care or treatment to the patient or client correctly.                                                                                                                                           

Documentation Formats


Although each facility may have their own method of maintaining their patientís records, there are several basic methods of organizing the Medical Record.  One approach is the traditional narrative approach resulting in a chronological order of the care rendered.


Narrative Charting


This method of documentation consists of a straight forward account of the patientís status, nursing interventions performed, and the patientís true response to those interventions. Charting is in the form of Progress Notes and Flow Sheets and will frequently accompany the Progress Notes. 

This method may not always be the best approach as it provides no logical order for reviewing the patientís problems. Although this method of charting is quite simple, it usually takes a longer time to actually perform.

Problem Oriented Charting


A second approach to charting is the "Problem Oriented Medical Record (POMR).  The PMOR has several components including: a compilation of the patientís baseline information, a problems list, a plan for each designated problem, and progress notes to define the progress of the patient.   


A common method of this type of charting is the "SOAP" Method of charting.  This method focuses on the patientís problems and provides a structure to address those problems. The SOAP Charting consists of the following:


            S Ė Subjective (What the patients complains of)

            O Ė Objective (What you as a healthcare provider actually see, touch, or feel)

            A Ė Assessment (Your conclusion based on subjective and objective data)

            P Ė Plan of Action (Your proposed interventions to solve the problem)

PIE Charting


PIE charting consists of a running list of nursing diagnoses, each with a progress note.  Each entry is divided into three categories. "P" is labeled as a Nursing Diagnosis.  "I" is labeled for the interventions the healthcare provider provided, and the "E" is the determination of the success of the intervention provided.


PIE charting provides a logical and easy to use format.  PIE charting permits you to document nursing process however it does not provide a central point for documenting planned care.  Therefore you would have to read several "shiftsí notes to verify all of the nursing actions performed for ach problem which is the major drawback to this method of documentation and charting.  

Focus Charting


Focus charting is typically organized by key words listed in columns.  These words may be a sign or symptom, a nursing diagnosis, a specific patient behavior, a significant event that happened to the patient, and or a change in the patientís present condition.  In one column is the key word and in the next column is the note on that subject including the actions you take including the patientís response. Although this method is sometimes more complex it often requires less written notations than the SOAP or PIE charting methods.   Some nurses believe this method of charting makes it easier to actually document the true nursing process.   


Charting by Exception


This method of charting requires that you document only significant changes or exceptions to the patientís norms.   These norms are based on clearly defined standards of practice for nursing assessments and the interventions you provided.

Specifically designed Flow Sheets are utilized in this form of medical charting and documentation.  You typically document explanations of the exceptions to the norm in written progress notes.


Although this method of documentation is more involved, charting by Exception frequently streamlines documentation and often saves time in actual charting time.


Computerized Charting


Since the evolution of computers, new formats of documentation have been developed.  The trend today is a move towards computer based documentation process to maintain the Medical Record. If your facility has not moved to a computerized method of documentation, get prepared as it probably will sometime in the near future.  


Healthcare facilities utilize the computer systems for a variety of medical related issues to include: medical billing, payroll, pharmacy supply, central supply ordering and much more.  Many hospitals now use specially designed computerized systems called Hospital Information Systems (HIS) that include Nursing Information Systems (NIS).   These systems allow the healthcare provider to perform a variety of tasks such as: generating Kardex forms, Vital Sign Reports, specific charting and assessment forms, Intake and Output Forms, Medication Sheets and much more.


The major advantage of computerized documentation is that a large volume of information is available quickly to the Healthcare Provider.  Personal computers or bedside computer terminals are frequently located in nursing stations and some are even located at the patientís bedside. 


To use the computer system, the Healthcare Provider must "Log on" with their Identification or Personal Identification Number (PIN). This number is assigned to you by the facility. Then you choose the specific function that is needed such as entering new data on the patient or retrieving past information such as laboratory values or pharmacy orders.  Using the computer method allows the healthcare provider to retrieve much more information quicker and easier than more conventional charting methods that would normally be more difficult and time Ėconsuming to retrieve.


Once the information has been imputed into the system, the information is available to all of those medical personnel having permitted access to the patientís records.  Some systems do restrict individuals from having complete access and allows that person only to access what the hospital allows.  An example might be nurses would be allowed to access medical records however they may not be able to access the personal billing records of the patient.        



Elements of Good Documentation

Prevent medical errors by documenting defensively.  The following advice on documentation includes issues identified through analysis of malpractice claims.

1.       Make sure you have the correct chart before you begin documenting your entries.

2.       Write legibly and neatly, print if necessary.  Date and time your entries, and sign them correctly: the first name or initial, last name, and professional credential (RN, LPN, CNA, and so on).

3.      Avoid grammatical and spelling errors; they make it hard to portray you as an educated professional.

4.      Abbreviations are easily confused.  The indiscriminate use of abbreviations can be extremely dangerous to you and the patient, besides being a major waste of time.  The less space you have for documentation, the more inclined you may be to abbreviate.  Be extremely careful when using flow sheets, as theyíre a breaking ground for unapproved abbreviations.  The tendency is to force a lot of information into small spaces, thereby avoiding having to document in the progress note.   Use only proper and accepted abbreviations approved and used by your facility and/or profession.  Avoid misleading abbreviations.  Next time you start to write an abbreviation, think about it.  Ask yourself if it is in the best interest of the patient, yourself, and your facility. 

5.      Be factual and descriptive.  Use objective information.  Rely on what you see, hear, feel or smell.  Subjective data, such as patient comments, should be entered in quotes.  Record the exact words as much as possible.  Provide clear, concise, accurate information.

6.      Donít guess, generalize or write personal opinions or statements.

7.      Make sure entries are accurately dated and timed. If you forgot to chart during a shift, make a "late entry" by writing the current date and time in the next available space and writing "Late entry for (date and shift missed)."  To add information to an existing entry, write the date and time of the new entry on the next available space and include: "Addendum to note of (date and time of prior note)."  Sign the entry as usual.  Donít try to squeeze in an entry between the lines.

8.      Always document with a jury in mind.  Donít try to change the chart with the intent to deceive.  Even if there are other mitigating circumstances, one piece of falsified documentation casts doubt on the entire record and can easily render a malpractice case indefensible.

9.      Do not erase, write over, or obliterate any entries in the chart.  This is illegal charting.  When incorrect information is written, draw a single line through the entry, date it, initial it, and then enter the correct information.

10.    Chart procedures and tests only after they are done, not in advance.

11.    Record the patientís symptoms and what you did in response to the problem, whether your action involved direct patient care or not.  How did the patient respond to your interventions?  Your charting should accurately reflect the patientís condition.

12.    Note communication among all health care team members.  Always document the date, time, and information conveyed, the name of the person notified, and his or her response.  Do not write vague notations such as "MD notified" or "family notified" as this can lead to confusion if that person needs to be identified.  Avoid writing "Dr. called" as this can easily be misinterpreted to mean that some doctor called you.

13.    If an Informed Consent is required, make sure you know both the state law and your hospitals policy.  In general, document that the procedure was explained and that the patient knowingly consented to it.  If the patient has a guardian, document the guardianship in your notes.  If the patient is a minor, document the facts of who signed.  If the patient doesnít speak English, make sure you document the translatorís name on the consent form and in the Nursesí Note.  If the patientís condition impairs his/her ability to give informed consent, document the observations, alert the doctor, and follow the state law and hospital policy.

14.    Chart all instances of patient noncompliance or refusal of recommended treatment.  Document that the patient was informed of the risks by not consenting and document his/her refusal.  Then notify your nurse-manager and the doctor.

15.    Transfer and discharge documentation includes medications, patient status (vital signs and health stability), and any teaching and or instructions given to the patient and his/her family members/guardian upon discharge.  Carefully and thoroughly document each action in the patientís chart.

16.     Protect your signature.  Do not leave any blank spaces before you signature on a chart.  Draw a line between spaces to your name, if necessary.

17.    If your facility allows charting by exception by utilizing flow sheets for documentation, fill out all spaces on these sheets even if itís only "N/A" for items that are not applicable or by drawing one single line through areas not utilized. Blank spaces raise doubts about whether something was performed or not.

Common Charting Mistakes to Avoid

Another side to medical documentation errors are the omission of documentation of patient information pertinent to their hospitalization, safety, and plan-of-care.  The following are the most common charting mistakes which can lead to medical errors.

1.   Failing to record pertinent health or drug information - Examples could include failing to include an allergy to medications or food, specific histories such as Diabetes, Glaucoma, Deafness, mental health disorders, etc. Make sure all allergies and pertinent health information is obtained on admission and is documented on the appropriate sheets according to your hospital policy.

2.   Failing to record nursing actions - Record everything you do for a patient on his/her chart as soon as possible.  For example, if the information regarding a dressing change is omitted, one might not realize that the patientís wound is draining more than it should or the nurse failed to change the dressing.

3.   Failing to record that medications have been given - Record every medication when you give it, when itís given, and include the dose, route and time.  An example of an medical error would be administering a second dose of a medication when there was no documentation that the ordered dose was already given.

4.   Recording on the wrong chart - Check your facilities policy on the system for flagging patientsí charts and medication records with similar names or other similar information that could cause confusion.  Also be careful in regard to patients in the same room having the same doctor or the same condition.

5.   Failing to document a discontinued medication - If the patient is supposed to be taken off a specific medication, you need to document the order promptly.  For example, if a medication is to be discontinued due to an adverse effect (such as a patient with an active bleeding ulcer who should not receive anymore aspirin), the continuation of administering more aspirin could lead to a deterioration of his/her condition.

6.   Failing to record drug reactions or changes in the patientís current condition - You need to document your observation of the patientís current health condition and your specific actions if any were taken, as well as documenting any patientís comments about his/or her changes in their condition..

7.   Transcribing orders improperly or transcribing improper orders - Anytime you are unsure about a drug order, check it with the prescribing doctor, your nurse manager or follow the policy of your facility.

8.   Writing illegible or incomplete records - Imagine your embarrassment at being called to testify and not being able to read your own handwriting or having to admit that the information recorded is incomplete.  To play it safe, remember each of these good charting practices:

             Print if your handwriting is difficult to read.

             Sign your full name and title somewhere on every page where youíve finished charted.

             Do not leave blank spaces, lines, or boxes on charts.  If you donít use the space, draw a line through it or write N/A (not applicable).

             Do not use abbreviations that are not on your facilityís approved list               Document enough to convince a reader that the patient was adequately treated or cared for.

 What Not to put in a Medical Record


If an incident occurs involving the patient, the healthcare provider must need to know "what does get documented" and just as importantly Ďwhat does not get charted" in the Medical Record.  The rule of thumb is that anytime a patient makes a specific complaint, it should be documented. If any error occurs such as a medication error, a medical device malfunctions, the patient or anyone else including staff member or visitor is injured or involved in a situation with the potential for injury, an Incident or Occurrence Report is required to be completed.   


The clinical observations of only the patient are recorded in the patientís Medical Record.  Make no mention of the "Incident Reportí in the patientís Medical Record.  The Incident Report is an administrative Risk Management document and not part of the patientís Medical Record. 


When documenting on the Medical Record, be certain to state only the facts and not speculations.  Example: You found the patient next to their bed on the floor. Therefore, you would document "Patient found on floor", state your assessment, any change in the patientís level of consciousness, and any treatment provided.  You would also document reporting the event to your nursing supervisor or by calling the doctor.  If you would have documented "patient fell out of bed onto the floor" it would be assumed you actually saw the patient fall to the floor.  Since you did not see the patient climb over the side rails and actually fall, what you actually document is "the patient was found on the floor and whether the bedside rails were up or down"    RememberÖ No Assumptions !


This segment is just to remind you of the importance of documenting incidents or unusual occurrences and the importance of documenting proper information on the proper forms.  Please refer to your facilityís actual policy and procedure guidelines in regard to any other information about incident/unusual occurrence reports or contact your nurse manager for further assistance.


Documentation Compliance Requirements


In order for a medically licensed healthcare facility to assure proper payment for the services rendered, proper documentation justifying the care given must be clearly provided in the Medical Record. The Medical Record provides the evidence of which payment decisions are made.  Insurance carriers as well as Medicare and Medicaid each require strict documentation compliance for payment reimbursement.    


The Medical Record must also show the organizational process of how care was rendered to the patient.  Because the Medical Record may be shared by several healthcare providers, it is important to understand the need for proper and legible documentation.   The Medical Record supports the patientís eligibility for medical coverage.


As an example, for Medicare reimbursement, Medicare requires the following:


1.  Patient Assessment tools must be used to reflect whether assessments were completed within a required period of time.


2.  Documentation that shows the patient has been informed of their "Rights" including the OASIS Privacy Notice about Advance Directives


3. A Plan of Care (POC) must be implemented describing the treatments and services that are to be provided


4.      Clinical Notes must be completed by the healthcare Provider rendering the care and that physicians were notified when changes in the patient status occurs.


5.      Documentation of care coordination between all of the disciplines of the patientís health care team


Medical Record compliance is frequently evaluated by various Compliance Surveyors that inspect the facility for licensing, accreditation, and or proper compliance. Surveyors use various guidelines to determine complete compliance.

Medical records are closely examined for proper documentation and assure the records meet the accreditationís guidelines. If the clinical records fail to reflect compliance, the Surveyor then goes deeper into the facilityís policies and or procedures to determine why the healthcare services does not meet the established standards. If the documentation is not accurate, the billed services may be reduced or completely denied, and the facility may be cited, fined, and or closed.  

Privacy of the Medical Record

Back on April 14, 2003, the first-ever federal privacy set of standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers became effective.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all health organizations to adopt and develop standard code sets to be used in all health related transactions. These policies and procedures should protect the confidentiality of protected health information about their patients. Virtually all health providers must implement these standards if they transact and communicate using paper, by phone or fax.  Although these requirements may allow for some flexibility, each provider must implement them as appropriate for their own facility.

Patients do have the right to view their own medical records.  Although specific arrangements are usually made available to the patient when viewing the medical record, patients also do have the right to make photocopies.  However, the patient may be charged for the costs of copying or mailing the records.  Employees must be trained in the specific privacy procedures policies their facility uses.

Typically a patient will receive a Notice of Privacy upon admission. The Notice will outline the "patientís rights.  These Patient Rights will include but are not limited to the following:

a.       The right to access their medical records

b.      The right to amend their record if contains errors

c.       The right to confidential communication

d.       The right to privacy

e.       The right to Opt Out of the Directory


Information may be shared with other treatment providers such as office staff, physicians, and other treatment facilities if there is a need to know.

In Conclusion

Attention to the quality of the medical record is everyoneís responsibility from the doctors writing the Physician Orders, to the Nursing Assistants that document the vital signs and Intake and Outputs, including record keeping and billing personnel who file the claims. All administrative personnel that maintain the Medical Records must be accountable. 

Only by proper documentation by all of the healthcare team can the patient expect a quality outcome.  Continued improvement in documentation must be maintained to assure quality patient care and to always reduce the liability of the healthcare provider should there be question.  Remember to always document as if your documentation was being read in court, it just might be.   




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