Writing Notes

My rule of thumb is to chart enough information so that all who follow me can easily see what I did for that patient and what their responses were. Be specific enough so that whoever reads your notes can be informed.

state the facts of the event in detail in the medical record. remember if its not documented, it didn't happen. see the code of federal register (highlighted in red) that must be in the medical record.

42 cfr ch. iv (10-1-05 edition) 482.25

medical record must be maintained for every individual evaluated or treated in the hospital.

(a) standard: organization and staffing. the organization of the medical record service must be appropriate to the scope and complexity of the services performed. the hospital must employ

adequate personnel to ensure prompt completion, filing, and retrieval

of records.

(b) standard: form and retention of record. the hospital must maintain a medical record for each inpatient and outpatient. medical records must be accurately written, promptly completed, properly filed and retained, and accessible. the hospital must use a system of author identification and record maintenance that ensures the integrity of the authentification and protects the security of all record entries.

(1) medical records must be retained in their original or legally reproduced form for a period of at least 5 years. (2) the hospital must have a system of coding and indexing medical records. the system must allow for timely retrieval by diagnosis and procedure, in

order to support medical care evaluation studies.

(3) the hospital must have a procedure for ensuring the confidentiality of patient records. in-formation from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. original medical records must be released by the hospital

only in accordance with federal or state laws, court orders, or subpoenas.

© standard: content of record. the medical record must contain information to justify admission and continued

hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.

(1) all entries must be legible and complete, and must be authenticated and dated promptly by the person

(identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished.

(i) the author of each entry must be identifed and must authenticate his or her entry.

(ii) authentication may include signatures, written initials or computer entry.

(2) all records must document the following, as appropriate:

(i) evidence of a physical examination, including a health history, performed no more than 7 days prior to

admission or within 48 hours after admission.

(ii) admitting diagnosis.

(iii) results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved

in the care of the patient.

(iv) documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia.

(v) properly executed informed consent forms for procedures and treatments specified by the medical staff, or

by federal or state law if applicable, to require written patient consent.

(vi) all practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information

necessary to monitor the patient's condition.

(vii) discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care.

(viii) final diagnosis with completion of medical records within 30 days following discharge.

i learned "chart on exception". we have flowsheets, obviously. i will usually write "assessment completed per flow sheet" with notes pertaining to whatever tubes the pt has, orientation, and then whatever the plan of care is, charting specific to that, regarding interventions and whatnot.

it usually ends up being 6 or 7 sentences.