Professional Writing Tips for Medical Charts & Client Documentation

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Presentation transcript:

Professional Writing Tips for Medical Charts & Client Documentation RECR 120

Medical Charts Paper or Electronic medical records are legal documents. Great care should be taken any time you document about a client.

Tips Use black ink only Do not use white out to make corrections Corrections – mark one line through error and put the date and your initials Use correct abbreviations Use legible handwriting Date and sign your name and credentials after each entry

Tips Do not back date – always use the correct date even if you are late documenting Check for spelling errors Fill out forms completely (patient name, ID #, room #. Etc) Check rules for making photo copies