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¶ … Provider Document Guidelines)
Provider Documentation Responsibilities
Summary of Key Concepts
Authentication of patient record entries
All entries in the medical record must contain the author's identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.
Abbreviations used in the patient record
All abbreviations use should be kept to an absolute minimum for effective and safe communication in patient care. Abbreviations should be avoided completely especially in drug prescriptions, operation lists and consent forms -- for example, the laterality of site of operation. Lists of approved abbreviations and their correct meaning should be established along with a list of 'Do not use' abbreviations to be followed by the healthcare professionals.
Legibility of patient record entries
The record must be legible to someone other than the writer. All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be dated, preferably timed, and signed by the author. Legibility of medical record documentation is not just a billing issue; it is a patient care issue. Illegible documentation may result in medication errors and incorrect diagnoses being assigned...
The medical record must be legible to an individual who is not familiar with the provider's handwriting. In addition, notes should be timed and dated appropriately. The timing of a medical record note is especially important in an inpatient chart, emergency department settings, trauma settings, and critical care units. It is especially critical that the identity of the provider of service be legible. Signatures should also include the provider's credentials.
Timeliness of patient record entries
All entries must be dated. Documentation should be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
Amending the patient record
To properly execute a medical record addendum, the provider must, at a minimum, write the following details in the medical record:
The date the record is being amended.
The details of the amended information.
A statement that the entry is an addendum to the medical record (it is not appropriate to add an addendum to the medical record without…
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