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record. However, late entries must list the date and time of the late
entry. If possible, chart why the entry was made late.
• Thorough: Describe actions taken and patient responses. Tell the
patient's story. "Physician notified," doesn't describe what was reported
to the physician nor does it outline a plan of care. Better documentation
would state, "Dr. Smith's office notified at 0930 of patient's uncontrolled
pain. Sue Jones, RN, stated that Dr. Smith will return call in 30 minutes."
Finally, never forget that all providers documenting in the record
should sign and date documentation.
Electronic or paper records
Whether your facility uses a paper chart, an electronic health record
or a hybrid of the two, patients should always have complete and correct medical records. There are pros and cons to each of these documentation systems but, from a legal standpoint, it's a lot harder to
hide errors if your facility uses electronic medical records. Many of
these systems make it impossible to skip areas of the chart by using
"required fields." They also provide accurate date and time stamps
that can demonstrate how timely you are with your charting.
Electronic records can also, however, introduce risk into your organization. Be careful when using "charting by exception" methodologies
and auto-recalls, and overusing alerts and flags.
Healthcare providers will often argue that documenting on paper is
"so much faster." The paper record is often what providers are used to
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