Documentation Best Practices

Write it Right

Protect your patients, your team and yourself by following these guidelines when writing your clinical notes.

Entries should be...

...OBJECTIVE

• Document your clinical rationale at critical decision points, e.g., a new finding or change in the patient’s condition. If appropriate, note the reason for diverging from standard practice
• Record the risk-benefit analysis of important decision.
• Don’t chart a symptom without documenting your response (response should meet the standard of care).
• Describe actions of the patient rather than labeling behavior: “pt has not kept scheduled appointment with GI” rather than “pt is difficult and non-compliant.”
• Avoid comments that could be viewed as disrespectful or prejudicial, e.g., attention seeking, histrionic, dramatic.
• Include socioeconomic information only if relevant to care.
• Document communication with other clinicians (if they are specific to the patient).
• Document patient education, instructions
• In addition to the patient, consider the “audiences” that may have access to patient records such as insurance companies, regulatory agencies.
• Avoid hearsay: do not record what someone else said, heard, felt, or smelled unless information is critical; use quotations and attribute remarks accordingly.

...SPECIFIC

• Avoid vague terms; e.g., write “9 x 5 x 1 cm wound” rather than “medium wound.”
• Beware copying and pasting review what is being copied to avoid perpetuation of information that is no longer accurate or relevant.

...TIMELY

• Notes should be recorded contemporaneously with medical care; a long time lapse before entry diminishes credibility.
• Late entries are appropriate for information that is missing or incompletely documented.

Avoid chart wars

• Do not joust in the record.
• Avoid criticizing other staff—current or former caregivers.
• Be aware that all relevant facts about prior care may not be available.
• Patient’s perceptions of care may be inaccurate.
• Conflicting chart entries undermine your credibility.
• Patient awareness of discordance may lead to loss of trust in caregivers.
• Use appropriate chain of command, not medical record, to address conflicts with other providers or administration.
• Do not prompt patients to consider litigation.
• Do not make assumptions; if something is not clear, get clarification.
• Do not amend or alter entries in the record without using the appropriate process.

Corrections/Addenda

• Paper: draw a line through incorrect entry with initials and the date. Provide corrected information.
• EHR: add a clearly marked addendum to the original entry with the corrected information; state the reason for the correction.
  Do not delete or make original information inaccessible.
• Do not make an addendum in anticipation of a claim or legal action because it may:
  • be characterized as an attempt to falsify or change the record of fact
  • appear to be “self-serving” rather than providing information that is needed for patient care
  • seem defensive, may not contribute to the care of the patient, and should be avoided

Published in June of 2013, Revised January 2021