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EMR Documentation Do's & Dont's Cheat Sheet by

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Do's of Charting

Do This

Stick to the facts—­because facts speak for themse­lves. (No one can argue with the facts, but they can argue with your opinions!)
Remain brief and to the point. You don’t need to write a “book” about your clients!
Be specific! For example, it’s not very helpful to write “client ate well”. Writing something like “client ate 75% of lunch tray” is much better.
Avoid docume­nting the same inform­ation about a client day after day. Observe each client carefully and document even small changes.
If you document directly in your clients’ charts, make sure you have the right one before you begin to write!
Include each client’s full name in your docume­ntation since there may be two clients with the same last name.
If you document a change in a client’s condition, be sure to write what you did about it. For example, if you document “Mr. Johnson gained 4 pounds since yesterday” , you should also document that you notified your superv­isor. You might write “Called Jane Doe, RN about weight gain. She said she will talk to doctor.

How to Handle Errors

If you left out important inform­ation, call your supervisor as soon as possib­le. Follow your workplace policy for charting late inform­ation.
Never correct someone else’s charting error. Instead, tell the person that you noticed a mistake in their docume­nta­tion.
Never erase/­delete an error in your docume­nta­tion.
Never use “White­-Out” is also against the rules.
Follow your workplace policy for correcting an errors. Usually, this involves drawing one line (red-l­ining) through the error and initialing it. Write “mistaken entry” and your initials next to it.
Note: Docume­nting “mistaken entry” is better than writing “error” since someone might think you made an error in care—not just in docume­nta­tion.
 

The Don'ts of Charting

Don't Do This:

Criticize the care given by any of your coworkers. Avoid writing about workplace problems like staffing shortages, too.
Chart a symptom without an Interv­ention.
Chart for someone else or write down what someone else tells you about a client.
Document a task that you did not do!
Write with a pencil...a­lways use ink.
Use two different colors of ink for the same entry. Someone might think you came back later to correct your initial charting.
Use language that sounds like you have negative feelings about a client. For example, instead of writing “client is drunk”, stick to the facts by writing “client’s breath smells of alcohol and he is slurring his words”.
Remove pages from a client’s medical record. Each page is a permanent, legal document.
Mention the name of one client in another client’s chart.
Document your client care ahead of time—even if it never seems to change from day to day

Caution About False Docume­ntation

Medical records are legal documents intended as a means to commun­icate between caregi­vers. When records are false, great harm and even death may come to the patient. In addition, including false inform­ation in a medical record is grounds for a malpra­ctice claim which could cost you and your employer countless hours and a lot of money to defend. Examples of false docume­ntation include:
Charting before you provide care. If you get busy and never perform the care you charted . . . you falsely documented it.
Charting that you provided care that you did not do.
Copycat charti­ng. This is charting what the previous shift charted without actually assessing the patient or performing the care on the client.

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