Rules for Writing in Medical Records

Question 1

Rule 1: Security

Answer 1

• keep paper medical records in fireproof, secure, locked file
• electronic medical records protected with password, time-out, privacy screen filters

Question 2

Rule 2: Authentication

Answer 2

• sign with credentials and date
• contemporaneous
• state practice act

Question 3

Rule 3: Complete

Answer 3

• all relevant info
• personal info: name, address, DOB, insurance, emergency contact, physician
• true reflection of episode of care: consent, intake forms, initial, interim, discharge documentation, progress reports to physicians, referrals
• special circumstances: cancelled appointments, conversations, verbal orders, unusual occurrences

Question 4

Rule 4: Timel

Answer 4

• contemporaneous
• accuracy of memories
• administration, reimbursement, quality control sharing across disciplines

Question 5

Rule 5: Relevant, Accurate, Logical

Answer 5

• avoid documenting unrelated info

- logical justification supports clinical thought process

Question 6

Rule 6: Objective

Answer 6

• factual, neutral language
• do not give opinion except as it relates to your clinical judgement about impairment
• avoid personality or psychologic status, taking sides, or ‘appears to be”

Question 7

Rule 7: Clear and Concise

Answer 7

• still needs to be thorough

- do not omit information to be brief

Question 8

Rule 8: Consistent

Answer 8

• setting specific information

- templates and forms

Question 9

Rule 9: Legible

Answer 9

-claims can be denied if not legible

Question 10

Rule 10: Scientific

Answer 10

• avoid using non-skilled terminology

- exceptions: pediatrics, school setting

Question 11

Rule 11: Skilled Language

Answer 11

-be specific about cues or assistance that is required

Question 12

Rule 12: Medical NEcessity

Answer 12

• why is intervention needed

- describe reasons in terms of evidence

Question 13

Rule 13: Patient Centered

Answer 13

• use 3rd person language to emphasize the patient

- rarely use 1st person only to describe special circumstance in narrative paragraph

Question 14

Rule 14: Organized

Answer 14

• use headings to group related info

- use tables, columns or lists when appropriate to draw eye to data

Question 15

Rule 15: Formatted

Answer 15

• write in permanent ink, black or blue, ballpoint
• industry standard abbreviations: facility approved
• don’t skip lines
• late entry or addendum documentation reserved for times when you may have left something out; write date that you are making notation
• errors make single line through text so it’s still legible and initial/date
• no correction fluid