1.
Records must be legible. Other care providers depend on
your records. They must be able to read them. You must be able to
read them 5 years from now.
2. Entries must be
dated. Include the year. 5 years later you won't know which
October it was.
3. Entries may be changed, but
not obliterated. If you notice an error, draw a single line
through the script, date and initial it, then make your
correction.
4. Note the date for follow-up.
Tell your patient when to follow up with you, but to let you know
sooner if any problems arise.
5. Note that consent
discussion has occurred. State that risks, benefits and
alternatives have been discussed. Patient questions should be
noted. If a family member is present, identify that person in your
record. Note that "patient requests cervical
adjustment."
6. Document patient
non-cooperation. If a patient misses appointments, fails to
comply with instructions about activities, or continues
detrimental actions, enter it in the record.
7.
Document phone calls. Note questions or comments. Follow up
should also be noted.
8. Document patient
education offered or provided. Note instructions given about
lifting, sleeping, or exercise.
9. Outside test
results should be noted. Initial a report received from an
outside MRI or other exams. Note when you discuss results with the
patient.
10. Don't leave blank spaces on the
page. Adding entries at a later time is unacceptable unless
accurately dated. Don't leave yourself open to accusations of
doctoring the records.
11. Entries must be
signed. Initials are acceptable, but signature is preferable.
Don't sign for someone else.
12. Records
must be written in ink. Go ahead and invest in a pen, it's a
business expense. Pencils are fine in 2nd grade, but not for
documentation.
13. Record normal findings as well
as abnormal. "If you don't record it, you didn't do
it."
14. Record patient comments about concurrent
care with other doctors. Also document your attempts to
receive information from other providers.
15. Use
standard abbreviations, or construct a glossary of your own
symbols.
16. Avoid critical comments about
other providers. Patient records are not the place for
performance reviews.
17. All pages must contain
the patients name and ID number. Goes without saying.
All
this in addition to the standard
SOAP.
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