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 Rules o 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 may use 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 Rules Do not leave any empty lines. Mark a straight line through unused space. Do not leave any empty lines. Mark a straight line through unused space. Document only facts. Document only facts. Use present or past tense. Never use future tense. Use present or past tense. Never use future tense. Example: Pt ate 100% of breakfast Example: Pt ate 100% of breakfast

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 should be documented? Objective Information Information that can be observed with the 5 senses. Information that can be observed with the 5 senses. Information that other people can verify Information that other people can verify Measurable information Measurable information

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?