So as discussed previously, patient
records are legal documentation.
So we need to know the do's and
the don'ts of medical documentation.
So let's look at this nurse's
note a little bit more closely.
So if you look at the top of this note, it says
nurse's note colon, Mr. Henry was really angry.
Let's pay attention to that part.
He wanted to have his wife, Miss Tiffany,
Let''s also pay attention to that part as well.
come to visit after visiting hours.
He was informed of the policy and his wife was
contacted to inform her of the hospital's visiting hours.
Signed, not me.
Okay, I'm not sure if you've seen a lot of medical
shows, this is probably not the most appropriate note.
So let's take a look at this a
little bit more closely, and in detail.
Okay, so we're looking at that earlier note, if
you notice in bold, it had "Miss Tiffany" earlier.
As you can imagine, Miss Tiffany
is probably the wife's first name.
So when we are doing professional
documentation, we want to come across professionally.
So here you can see how we've changed it to Mrs. Henry.
So we want to look through our documentation
and correct all those errors promptly.
The next thing to note is that the
earlier notes stated Mr. Henry was angry.
So here's the problem with that.
This sounds like personal opinion, correct.
So when we're documenting, we
need to be conscientious of this.
So record all facts, and no personal opinions.
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.
Also take note the length of this note.
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.
And lastly, make sure you write
legibly in permanent black ink.
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.
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.
Alright, so when we look further at
this note, when was it documented?
What day, what time we have no idea.
So we need to be specific in this documentation.
So we're gonna begin each
entry with the date and the time.
Also, if you notice the end of
this note, it says 'signed, it's me'.
Well, who's it's me? So if you look at this
note later, we're not going to know who "me" is.
So obviously make sure you chart for yourself and make
sure you sign your name and your credentials at the end.
Okay, so now that we finished looking at
each piece, now let's look at this note individually.
Note now that there's a date and a time.
Note, there's no personal opinions there.
Notice we don't have large gaps in the documentation.
And it's actually signed by
the nurse who documented it.
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.
I'm gonna repeat it again, keep
your computer password secure.
If someone else uses it, if you keep your screen up and
you don't log out, this actually can be a HIPAA violation.
So keep this in mind.