Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Golden Rules of Chart Documentation

Jan Rebstock RHIT, LHRM, CPHRM
2-2-3 For those who have worked in health care a few decades, reflecting over the past often lends credence to the old saying that “the more things change the more they stay the same.” The significant uses of the medical record and principles of chart documentation are as old as dirt, yet achieving consistent adequate, accurate, and legible documentation seems to be an elusive goal. Ergo, constant reinforcement and diligence is required. Consider the following uses of the medical record:

Continuum of Care: Health care providers make clinical decisions based on what has been documented by other care providers. Poor or inaccurate documentation of assessments can result in unnecessary duplicative tests, delays, and errors in diagnosis.

Legal: Recognizing that memory dims over time and most cases are tried in court years later, it is easy to understand why many are lost or result in unnecessary negotiated settlements because of poor documentation.

Billing: Significant payment denials are frequently made by third party payers due to the inability to verify services rendered because of scanty documentation.

Research: Reliance on inaccurate, insufficient documentation can result in wrong conclusions that could have far reaching deleterious effects.

Regulatory Compliance: Findings of noncompliance can often be attributed to lack of documentation resulting in citations, fines, and, in some instances, program termination.

Some Shalts and Shalt Nots:

1. Thou Shalt Document Timely, Adequately, and Accurately.

2. Thou Shalt Write Legibly.

3. Thou Shalt Document Objectively and Factually.

4. Thou Shalt Not Intentionally Alter The Medical Record.

5. Thou Shalt Not Use Unapproved Abbreviations.

6. Thou Shalt Not Leave Blank Spaces on Required Forms.

7. Thou Shalt Not Use “White Out” to Make Corrections in the Chart.

8. Thou Shalt Date, Time, and Sign All Record Entries.

9. Thou Shalt Read What Thou Cosigns.

10. Thou Shalt Not Use Pencils To Document.

  “So let it be written. So let it be done.” Yul Brynner