Medical Records• A collection of the patient’s medical information• Owned by the healthcare provider• Patient may have a copy• Is a legal document and may be

used in court

Written consent is required to…

• Copy medical record for the patient

• Send a copy of medical record to another healthcare provider

• Allow another individual (family member) to have access to the medical records

Charting Rules• Hand writing should be neat

and legible.• No ditto marks, white out, or

erasing.

• If a mistake is made, mark one line through it, write error above it, and initial. Never throw any part of the chart away.

Charting Ruleso Record in the chart immediately after

completing each task.

o Be exact! Give specific details related to size, location, amount, time, procedure, etc.

Don’t use words such as “small”, “many”.

o Date all entries into the chart and note the time in military time.

Charting Rules Be clear and concise. You mayuse fragments!

Use appropriate abbreviations.

Don’t have to write the patient’s name. If your writing in the patient’s chart, we know you are talking about the patient. Can refer to him/her as Pt.

Charting RulesCharting Rules• Do not leave any empty lines. Do not leave any empty lines.

Mark a straight line through Mark a straight line through unused space.unused space.

• Document only facts.Document only facts.

• Use present or past tense. Use present or past tense. Never use future tense. Never use future tense.

• Example: Pt ate 100% of Example: Pt ate 100% of breakfastbreakfast

Charting Rules

• Sign the entry with you first initial, your last name, and your title.

• Example: B.Reed, RN L. Jordan, RN

What type of information What type of information should be documented?should be documented?

Objective Objective InformationInformation

Information that Information that can be observed can be observed with the 5 senses.with the 5 senses.

Information that Information that other people can other people can verifyverify

Measurable Measurable informationinformation

Examples of Objective Information

2 inch laceration to right knee

Blood in wound bed

No signs of infection noted

What type of information should not be documented?

Subjective Information Information that

cannot be observed with the 5 senses

Information that others cannot verify

Information that cannot be measured

Information that is your opinion

Examples of Subjective Information Large cut on leg

Pt seems in pain

Small amount of blood on band aid

Pt stated “I fell and cut my knee”. (This is acceptable with “ “ )

Privileged Communications Legally, all

information given to the healthcare provider by the patient is protected under privileged communication.

Cannot be shared with others without written consent.

Information EXEMPT from requiring informed consent:

Assault & Battery Abuse Violent acts Births Deaths STD’s Communicable

diseases

Answer the following questions:

1. What is a medical record?2. What type of information is in a

medical record?3. Who can put information in the

medical record?4. Who owns the medical record?