Medical Record Documentation: Do's and Don'ts (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 So as discussed previously, patient records are legal documentation.

    00:06 So we need to know the do's and the don'ts of medical documentation.

    00:11 So let's look at this nurse's note a little bit more closely.

    00:16 So if you look at the top of this note, it says nurse's note colon, Mr. Henry was really angry.

    00:23 Let's pay attention to that part.

    00:25 He wanted to have his wife, Miss Tiffany, Let''s also pay attention to that part as well.

    00:31 come to visit after visiting hours.

    00:34 He was informed of the policy and his wife was contacted to inform her of the hospital's visiting hours.

    00:42 Signed, not me.

    00:44 Okay, I'm not sure if you've seen a lot of medical shows, this is probably not the most appropriate note.

    00:50 So let's take a look at this a little bit more closely, and in detail.

    00:55 Okay, so we're looking at that earlier note, if you notice in bold, it had "Miss Tiffany" earlier.

    01:02 As you can imagine, Miss Tiffany is probably the wife's first name.

    01:06 So when we are doing professional documentation, we want to come across professionally.

    01:11 So here you can see how we've changed it to Mrs. Henry.

    01:15 So we want to look through our documentation and correct all those errors promptly.

    01:22 The next thing to note is that the earlier notes stated Mr. Henry was angry.

    01:28 So here's the problem with that.

    01:30 This sounds like personal opinion, correct.

    01:33 So when we're documenting, we need to be conscientious of this.

    01:36 So record all facts, and no personal opinions.

    01:43 So how we get away with that nursing is if state, Mr. Henry stated that he was angry because, and of course, we want to make sure that patient states that but by using their own language, this is more tangible evidence that we can legally document.

    01:58 Also take note the length of this note.

    02:01 Do you notice that large gap in between? There's a large blank in between this documentation and we want to minimize that in our documentation to make sure that there's nothing that can be squeezed in between there.

    02:15 And lastly, make sure you write legibly in permanent black ink.

    02:19 So if you're using an electronic record, clearly this won't be a problem but some facilities may still have you do written documentation.

    02:27 Therefore make sure you're using ink, not pencil so you can erase it or anyone else can erase it and make sure you write legibly so all can read.

    02:37 Alright, so when we look further at this note, when was it documented? What day, what time we have no idea.

    02:43 So we need to be specific in this documentation.

    02:47 So we're gonna begin each entry with the date and the time.

    02:52 Also, if you notice the end of this note, it says 'signed, it's me'.

    02:56 Well, who's it's me? So if you look at this note later, we're not going to know who "me" is.

    03:01 So obviously make sure you chart for yourself and make sure you sign your name and your credentials at the end.

    03:09 Okay, so now that we finished looking at each piece, now let's look at this note individually.

    03:15 Note now that there's a date and a time.

    03:18 Note, there's no personal opinions there.

    03:21 Notice we don't have large gaps in the documentation.

    03:25 And it's actually signed by the nurse who documented it.

    03:28 One thing to keep in mind if you are charting on the computer, which a lot of us will be, make sure you keep your computer passwords secure.

    03:38 I'm gonna repeat it again, keep your computer password secure.

    03:43 If someone else uses it, if you keep your screen up and you don't log out, this actually can be a HIPAA violation.

    03:50 So keep this in mind.

    About the Lecture

    The lecture Medical Record Documentation: Do's and Don'ts (Nursing) by Samantha Rhea, MSN, RN is from the course Patient Education, Documentation and Informatics (Nursing).

    Included Quiz Questions

    1. Chart only for themselves
    2. Begin each entry with a date and a time
    3. Record their personal opinion of the situation
    4. Write in blue or black ink
    5. Leave blank spaces between notes
    1. Keep the computer and computer password secure.
    2. Allow all staff to have the same computer password.
    3. Minimize the screen whenever the computer is occupied.
    4. Leave the electronic medical record up only at the nurse's station.

    Author of lecture Medical Record Documentation: Do's and Don'ts (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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