1. Professional Writing Tips for Medical Charts & Client Documentation
RECR 120

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

3. 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

4. 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