Lakeland Community College Do's and Don'ts of Documentation PDF
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Uploaded by wgaarder2005
Lakeland Community College
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Summary
This document provides guidelines for effective medical charting, including dos and don'ts. It emphasizes the importance of accurate, objective, and timely charting to ensure proper patient care. Key factors, such as clarity, accuracy, and reflection of the care provided, are stressed.
Full Transcript
**Lakeland Community College** **Do's and Don'ts of Documentation** +-----------------------------------+-----------------------------------+ | **Do's** | **Don'ts** | +===================================+===================================+ | - Ch...
**Lakeland Community College** **Do's and Don'ts of Documentation** +-----------------------------------+-----------------------------------+ | **Do's** | **Don'ts** | +===================================+===================================+ | - Chart a patient's change in | - Do not chart in advance of | | condition and actions taken | events | | | | | - Read the nurses notes prior | - Do not use vague terms | | to care to determine if a | | | there has been change in | - Do not chart for someone else | | patient condition | | | | - Do not use patient instead of | | - Be timely. Late entry is | patient's name | | better than no entry. Greater | | | the length of time between | - Do not alter the record even | | care and charting, can | if asked by a physician | | diminish accuracy | | | | - Do not record assumptions or | | - Use objective, specific, | words reflecting bias | | factual descriptions | | | | Example: "complainer" | | - Correct any charting errors | | | per agency requirements | | | | | | - Correct spelling | | | | | | - Chart all teaching | | | | | | - Record the patient's actual | | | words, use quotation around | | | words. | | | | | | - **Chart the patient's | | | response to interventions** | | | | | | - Review what you write. Is it | | | clear, accurate, reflective | | | of the care provided. | | +-----------------------------------+-----------------------------------+
