MEDICAL RECORDS MANAGEMENT

AND PATIENT’S CHART

Submitted by:
Salve Boridas, R.N.
 HEALTH CARE RECORDS – DOCUMENTATION AND MANAGEMENT

PURPOSE
The purpose of this policy is to:
Define the requirements for the documentation and management of health care records
across public health organizations’ (PHOs) in the public health system.

Ensure that high standards for documentation and management of health care records are
maintained consistent with common law, legislative, ethical and current best practice
requirements.

MANDATORY REQUIREMENTS
Documentation in health care records must provide an accurate description of each patient
or client’s episodes of care or contact with health care personnel. The policy requires that a health
care record is available for every patient / client to assist with assessment and treatment,
continuity of care, clinical handover, patient safety and clinical quality improvement, education,
research, evaluation, medico-legal, funding and statutory requirements.

Health care record management practices must comply with this policy.

IMPLEMENTATION
Chief Executives are responsible for:
 Establishing mechanisms to ensure compliance with the requirements of this policy.
 Ensuring health care personnel are advised that compliance with this policy is part of
their patient / client care responsibilities.
 Ensuring line managers are advised that they are accountable for implementation of
this policy.
 Ensuring implementation of a framework for auditing of health care records and
reporting of results.
 Ensuring health care records are audited and results reported within the PHO.
Facility / service managers are responsible for:
 Ensuring the requirements of this policy are disseminated and implemented in their
hospital / department / service.
 Ensuring health care personnel within their facility / service have timely access to
paper based and electronic health care records.
 Monitoring compliance with this policy, including health care record audit programs,
and acting on the audit results.
Health care personnel are responsible for:
 Maintaining their knowledge, documentation and management of health care records
consistent with the requirements of this policy.
 Ensuring they are aware of current information about the patient / client under their
care including where appropriate reviewing entries in the health record.

MEDICAL RECORD POLICIES AND STANDARDS

Policies and standards are important in medical record management to achieve a more-uniform
practice for effective medical records management. Standards and policies suggest two things
which are consensus and guides.
Policies and standards are crucial, but their application may not fit every possible situation
encountered, most especially where material resource is lacking. Hence, modifications which may
mean deviations from standards shall be warranted.

Modification should not deviate from the standard to the extent of adversely affecting the level of
performance and quality of patient care. The patient's record should contain complete and
accurate set of information to facilitate effective patient care and its evaluation.

1. STANDARDS
An accurate record is maintained to facilitate optimal patient care and allow for evaluation of
the care provided.
1.1 The record is sufficiently detailed to enable:
a) The patient to receive continuing care
b) Effective communication within the health team
c) The Attending Physician to have available information required for the consultation
d) Other medical practitioners and health personnel to assume the patient care e)
Concurrent or retrospective evaluation of patient care
1.2 Entries into the records are made only by duly authorized persons of the facility and are
dated and signed, containing designation.
1.3 All entries, including alterations, must be legible.
1.4 Only abbreviations and symbols approved by the Medical Record Committee are to be
used.
1.5 If possible, original copies of all reports made by medical, nursing, and allied health
professionals are filed in the record.
1.6 Each record should at least contain the following data:
a) A unique medical record number or reference
b) Patient's full name
c) Address
d) Date of birth
e) Sex
f) Person to notify in case of an emergency
1.7 An "ALERT' notation, for the conditions such as allergic responses and drug reactions, is
prominently displayed on the face sheet of the record.
1.8 The record contains a written admission diagnosis by the medical practitioner.
1.9 The record contains a patient's history, pertinent to the condition being treated, including
relevant details of:
a) Present and past medical history
b) Family history
c) Social considerations
1.10 A sufficiently detailed report of a relevant physical examination (PE), performed by a
medical practitioner, should be included for the purpose of admission.
1.11 Evidence that the patient has given informed consent is available.
1.12 Drug orders are written in the record by the medical staff.
1.13 Therapeutic orders and orders for special diagnostic test are noted in the record.
1.14 There is evidence in the medical record that patient care plans were made.
1.15 Progress notes, observations, and consultation reports are written by medical, nursing,
and allied health staff to record all significant events such as alterations in the patient's
condition and responses to treatment.
 1.16 The front sheet is completed at the time of discharge or as soon as the relevant
information is available. It contains all relevant diagnoses and procedures using the
terminology of a current revision of the International Classification of Diseases (ICD).
1.17 A discharge summary for each patient should be completed within 48 hours of patient's
discharge, with a copy remaining- in the medical record. The discharge summary should at
least include the following:
a) Discharge diagnosis
b) Procedures performed
c) Follow-up arrangements
d) Therapeutic orders
e) Patient instructions (where necessary)
When a patient is transferred to another facility, a discharge summary should accompany
him/her.
1.18 When an autopsy is performed, a provisional diagnosis is noted in the medical record within
72hours and the medical record is completed within 15 days following the death. A copy of
the autopsy report is filed in the medical record.

2. RECORD COMPLETION
2.1 The medical record should be completed within 48 hours after the discharge of the
patient.
2.2 History and PE should be completed within 24 hours after admission.
2.3 An incomplete chart, not completed within 15 days after patient's discharge, shall be
considered a delinquent chart.
2.4 The attending physician has the final and major responsibility for completeness and
accuracy of the data entry in the record. He is also encouraged to raise the level of quality
of the individual health record and sustain a high level of recording.
2.5 Residents and interns may be delegated the duty of recording medical information as
history, PE, and discharge summaries. Their entries have to be reviewed, corrected, and
countersigned by the attending physician.
2.6 The Medical Record Practitioner assists the attending physician in reviewing records for
completeness by checking for omissions and discrepancies and helps ensure that medical
records comply with set policies and standards.

3. RELEASE OF INFORMATION
Release of health information is a very sensitive issue in several respects. The confidentiality of the
medical record should always be the concern of people involved in the release of health
information.
3.1 General Policies
3.1.1 The hospital shall safeguard all information contained in the health record against
loss, destruction, or unauthorized use.
3.1.2 All information in the health record shall be treated as confidential and shall be
disclosed only to authorize individuals.
3.1.3 It shall be the policy of all government hospitals not to use the medical record in any
way which will jeopardize the interest of the patient. But the hospital may use the
record to defend itself against any accusations.
3.1.4 The release of information is delegated to the supervisor of the MRS. But in cases
where the medical record practitioner encounters problems regarding the release of
information, the matter should be referred first to the Administrative Officer (AO), or
to the Chief-of Hospital (COH) for proper solution.
 3.1.5 No release of information with clinical value shall be done without written consent
from the patient himself.
3.1.6 The medical record is the physical property of the hospital. However, since the
information written on the record is the patient's personal history, he/she also has a
right to the said record. In cases where litigation is likely to happen and is intended
against the hospital or any other personnel of the health care facility, the Medical
Director/COH may refuse or deny access to the record even with the patient's written
authorization, until the court declares otherwise.
3.1.7 Request for medical certificate or clinical information when the patient is still confined
shall be referred to the attending physician.
• Should the AP decide to release the certificate while the patient is still confined, a
Certificate of Confinement shall be issued.
• No certificate of confinement shall be issued where the patient concerned is already
discharged, instead, a medical certificate shall be issued.
• No medical certificate shall be released without the signature of the Chief of
Professional Staff and the hospital seal.
• On the other hand, no medico-legal certificate shall be released without the
signature of the Director/COH and the hospital seal.
3.1.8 Information of no clinical value can be disclosed by the staff of the health care facility.
However, hospital policy should first be consulted and utmost care taken into
consideration before the release of non-clinical information. Such information includes the
following:
• Name
• Address
• Attending physician
• Name of relative with patient during admission
• Admission and discharge dates
3.1.9 Where the patient is a minor, consent of either one of the parents or the legal
guardian shah be secured before any information of clinical significance is released.
3.1.10 The medical record shall not be taken out of the hospital premises except on court
orders. Those authorized to do research and studies shall use the records inside the
MRS.
3.1.11 Incomplete medical records shall be referred to the attending physician before
entertaining any request to access and review the medical record.
3.1.12 In cases where the patient is in critical condition and does not have someone with
him/her to give consent, the medical record practitioner shall release, information only
after consultation with the Director/COH.
3.1.13Verbal request for clinical information shall be discouraged in favor of written
requests.
3.1.14The staff of the Medical Social Service (MSS) shall have access to the medical records
for purposes of establishing patient classification. They may also reveal the social content
of the record to organize and reputable social agencies who have a legitimate reason for
inquiry.
3.1.15 Information may be released to other health care facilities, upon written request, that
the patient is now under care.
3.1.16 Hospital management may, at its discretion, permit the use of medical records for
research and studies, only stressing that no information which will directly identify the
patient shall be published.
4. POLICIES FOR DOCTOR'S RELEASE OF INFORMATION
4.1 Doctors and members of the allied health profession may review records of patients
presently under their care.
4.2 Doctors who are members of the medical staff but not members of the team assigned
to the patient shall be armed with a written authorization signed by the patient before
they are given access to the record.
4.3 The privilege against disclosure belongs to the patient and not the treating physician,
therefore, the patient has the right to claim for it or waive it. In which case, the doctor's
approval is technically not necessary. But it would be a good practice to notify the
doctor prior to release of any information, as a sign of courtesy.
4.4 The hospital management may permit use of the medical record for research and
studies, the medical record being the physical property of the hospital. The hospital may
also withhold access to the medical record until a subpoena is issued.
4.5 Outside doctors intending to do some research/studies in a particular hospital shall seek
the written approval of the management before they are given access to the medical
record.
4.6 Insurance company doctors shall need proper written authorization from the patient, or
a duly accomplished insurance waiver, before they are given access to medical record.
4.7 Company physicians who are presently caring for a patient shall be given medical
information only upon presentation of a formal request addressed to the MRS.
4.8 Consultants shall have access to records of patients referred to them.
4.9 Resident doctors and the rest of the medical staff may request the MRS for records
'needed for their research and studies. But in cases where there is suspicion that their
wish to access will jeopardize the right of the patient, doctor-and the institution, access
shall be denied by the medical record staff.
4.10 It shall be the responsibility of the attending physician to inform his patient about his
medical condition.

5. POLICIES FOR NURSES ON RELEASE OF INFORMATION

5.1 Nurses may borrow/sign-out old records per doctors’ instruction for ward use.
5.2 In the ward, student nurses shall have access to the records of patients assigned to
them.
5.3 Private nurses’ shall only be allowed to review records of those patients assigned to
them.
5.4 All staff nurses may be given access to medical records not assigned to them for
purposes of conferences and case presentations. After the conference, the record shall
be returned to the MRS.
5.5 Ward nurses may review all records for purposes of compliance to requirements before
forwarding said records to the MRS.
5.6 Ward nurses should always see to it that charts are in a secure place away from the
patients or the patient's relative.

6. OTHER PEOPLE CONCERNED

6.1 The lawyer representing a patient shall only be given access after presenting a written
authorization duly signed by the patient.
6.2 An insurance verifier shall be required a waiver before being given access to the
record/information about a patient. The original copy of the waiver shall also be
countersigned' and dated by the insurance verifier and shall be filed with the record.
 *Insurance verifiers representing the Social Security System (SSS) and the Government
Service Insurance System (GSIS) shall review medical records for compensation
purposes per Warranty No. 10ofthe Philippine Medical Care Commission (PMCC).
6.3 Researchers from other medical institutions could gain access to medical records only
after complying with requirements set by the institution concerned.
6.4 Patient's relative making inquiries about their patient shall be referred to the attending
physician.
6.5 Law enforcement agents (Philippine National Police (PNP), Philippine Constabulary (PC),
National Bureau of Investigation (NBI) and others) shall need a written request duly
signed by the Chief/Director of their respective agency before being given access to the
record. Should it be possible however, to get the written consent of the patient, a
written request from their agency is no longer necessary.
6.6 Patients also have a right to their record. But to prevent misinterpretation of medical
information which may lead to litigation, patient may not be allowed access to his own
record. However, his physical and mental condition shall be explained only by the
attending physician. .'
6.7 The health care facility may, in some situations, release health information even without
the written authorization. Such situations are as follows:
6.7.1 Court Order. A hospital or other health care facility must release health
information in response to court orders.
6.7.2 Administrative Agency Order. A provider must release health information when
there is an adjudicative order from an administrative agency authorized by law.
6.7.3 Subpoena. In a court proceeding, a party or an administrative agency may issue a
subpoena, subpoena duces tecum, or notice to appear covering health information
held by a health provider. Where the subpoena is valid, the hospital must disclose
the health information.
6.7.4 Arbitration Order. Either an arbitrator or an arbitration panel may issue an order
authorizing the discovery of health information in an arbitration proceeding.
6.7.5 Search Warrant. A government law enforcement agency which has been issued a
search warrant is entitled to receive any health information covered by the
warrant.
6.7.6 Medical Research. Health information may be disclosed to public agencies, clinical
investigators, health care research organizations or accredited education or health
care institutions for purposes of bonafide research. But before the medical
information is released, the medical record staff should take reasonable steps to
ensure that the research is legitimate, and proper safeguards in the release of
information are instituted.

MEDICO-LEGAL ASPECTS OWNERSHIP OF THE MEDICAL RECORD

The medical record is the physical property of the health care facility and is maintained for the
benefit of the patient, the physician, the health care facility and the community. As a general rule,
ownership carries with it the right and power to control the utilization of the said property. For
medical records, ownership is not absolute because the patient also has a right to the information
written on the record, that being his health history.

ACCESSIBILITY AND CONFIDENTIALITY

As a general rule, all the people who are directly involved in the treatment of a patient shall have
access to the record.
The medical record is a legal document, as such, all records shall be stored in areas where only
authorized staff are allowed access and appropriate security measures are instituted. No
information concerning a patient or client shall be released to another person without the consent
of the patient.
• Where the patient is a minor, a person below 18 years of age, authorization of the parent
or legal guardian should be obtained.
• If the patient has died, the consent must be signed by the identified next of kin, or by the
administrator or executor of the decedent's estate.
• In the event the patient is unable to sign the authorization by reason of physical or mental
disability, the authorization should be signed by the next of kin or the legally appointed
guardian. If possible verification of such disability should be obtained from a physician.
• A person who is a minor but is married or self- supporting and living apart from his/her
parents may sign his own authorization.
• In general, because the medical record is the physical property of the health care facility,
they should not be taken out of the hospital except on court orders.

REQUEST FOR INFORMATION FROM DOCTORS OR HEALTH INSTITUTION REQUIRED

FOR CONTINUING PATIENT CARE

Advances in health care delivery gave rise to what is known as the "team care approach" to health
care delivery. This requires a wider range of health professionals who might have a legitimate
need for access to information from the medical record. In this sense, institutions should formulate
guidelines to restrict access to records to those who are only actually involved in the care of a
particular patient.

REQUEST FOR INFORMATION FROM THE MEDICAL RECORD FOR RESEARCH AND
STUDIES

Health care facilities are said to own the medical records, but legally, the "privilege against
disclosure belongs to the patient and nobody else." In a hospital setting, proper notification of the
attending physician, prior to the release of information is ideal, in order to protect the legal
interest of the doctor and the hospital as well.

In cases of research and studies, the hospital management may decide on who can and who shall
not be given access to the medical record, the record being the hospital's physical property. While
the hospital may give access to a patient's medical record for research, study, and publication, the
court of law emphasizes the need to protect the identity of the patient, which explains why the
name of the patient is not mentioned in these published reports.

A research proposal to be presented for approval should be accompanied by a comprehensive

protocol detailing the objectives methods and reasons for the study. Records for research
purposes should not be removed from the health facility.

Policies with Documentation Implications

All organizational P&P are important. From the legal, accreditation, and regulatory perspective,
documentation validates or proves compliance with P&P. Certain policies have particular
implications for documentation.
Some of these include:
• Abbreviations: Do Not Use List
• Admission, Transfer, and Discharge
• Advance Directives
• Patient Assessment
• Cardiac/Respiratory Resuscitation
• Chain-of-Command
• Crash Carts
• Hazardous Materials
• Incident Reports
• Infection Control and prevention of specific infections such as catheter-associated urinary
tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and
ventilator-associated pneumonia
• Medication Administration
• Medication Reconciliation
• Pain Management
• Patient Fall Prevention
• Rapid Response Team, or other system to respond quickly to deteriorating patient condition
• Restraints
• Safe Medical Devices
• Sedation
• Sentinel Events
• Suspected Abuse
• Skin Care
• Workplace Violence

The Patient's Medical Record or Patient’s Chart

“If you think of the medical record first and foremost as clinical communication that you
documented carefully, you need not panic if the court subpoenas it. However, if you think only of
legal implications or document to protect yourself, your part of the medical record will sound self-
serving and defensive. Such documentation tends to have a negative impact on a judge and jury”
(Lippincott, Williams & Wilkins, 2008).

The medical record, also called the patient’s record or the chart, serves four major purposes.
1. Acts as a vehicle for communication among members of the healthcare team.
2. Documents compliance with standards of care and standards of various accrediting
organizations such as TJC and the state health department.
3. Documents compliance with standards that must be met for reimbursement by a third party
payor such as Medicare, Medicaid, or another insurance carrier.
4. Documents that patient care meets safe, effective, and legal requirements.

Common Charting Errors

Common charting mistakes to avoid include the following:
1. Failing to record pertinent health or drug information
2. Failing to record nursing actions
3. Failing to record that medications have been given
4. Recording in the wrong patient’s medical record
 5. Failing to document a discontinued medication
6. Failing to record drug reactions or changes in the patient’s condition
7. Transcribing orders improperly or transcribing improper orders
8. Writing illegible or incomplete records

Documentation Standards

Healthcare organizations establish documentation policies based upon standards set by

organizations such as American Nurses Association’s Principles for Nursing Documentation, Nursing
Specialty Organizations published standards of practice and competencies, The Joint Commission
(TJC) developed Accreditation Standards and National Patient Safety Goals, Nurse Practice Acts,
and etc.

All aspects of care that standards mandate must be documented as evidence that care was
provided.
All sources of documentation standards and requirements emphasize:
Ongoing assessment
• Patient teaching, including the patient’s response to teaching and indication that the
patient has learned.
• Response to all medications, treatments, and interventions.
• Relevant statements made by the patient. Your organization’s P&P are the standard
against which your practice is judged in a court of law or in any disciplinary proceeding.

Documentation Characteristics and Entries

High quality documentation is:

• Accessible
• Accurate, relevant, and consistent
• Auditable
• Clear, concise, and complete
• Legible/readable (particularly in terms of the resolution and related qualities of EHR content as
it is displayed on the screens of various devices)
• Timely, contemporaneous, and sequential
• Reflective of the nursing process
• Retrievable on a permanent basis in a nursing-specific manner

Entries into organization documents or the health record (including, but not limited to, provider
orders) must be:
• Accurate, valid, and complete;
• Authenticated; that is, the information is truthful, the author is identified, and nothing has
been added or inserted;
• Dated and time-stamped by the persons who created the entry;
• Legible/readable; and
• Made using standardized terminology, including acronyms and symbols.

Identification on every page / screen

The following items must appear on every page of the health care record, or on each screen of an
electronic record (with the exception of pop up screens where the identifying details remain visible
behind):
a) Unique identifier (Unique Patient Identifier, Medical Record Number).
b) Patient / client’s family name and given name/s.
c) Date of birth (or gestational age / age if date of birth is estimated).
d) Sex. The exception is ObstetriX records where sex of the mother is not recorded.

Standards for documentation

Documentation in health care records must comply with the following:

a) Be clear and accurate.
b) Legible and in English.
c) Use approved abbreviations and symbols.
d) Written in dark ink that is readily reproducible, legible, and difficult to erase and write
over for paper based records.
e) Time of entry
f) Date of entry
g) Signed by the author, and include their printed name and designation. In a
computerized system, this will require the use of an appropriate identification system
eg. Electronic signature.
h) Entries by students involved in the care and treatment of a patient / client must be
cosigned by the student’s supervising clinician.6
i) Entries by different professional groups are integrated. Eg. There are not separate
sections for each professional group.
j) Be accurate statements of clinical interactions between the patient / client and their
significant others, and the health service relating to assessment; diagnosis; care
planning; management / care / treatment/ services provided and response /
outcomes; professional advice sought and provided; observation/s taken and results.
k) Be sufficiently clear, structured and detailed to enable other members of the health
care team to assume care of the patient / client or to provide ongoing service at any
time.
l) Written in an objective way and not include demeaning or derogatory remarks.
m) Distinguish between what was observed or performed, what was reported by others
as happening and / or professional opinion.
n) Made at the time of an event or as soon as possible afterwards. The time of writing
must be distinguished from the time of an incident, event or observation being
reported.
o) Sequential - where lines are left between entries they must be ruled across to
indicate they are not left for later entries and to reflect the sequential and
contemporaneous nature of all entries.
p) Be relevant to that patient / client.
q) Only include personal information about other people when relevant and necessary
for the care and treatment of the patient / client.
r) Addendum – if an entry omits details any additional details must be documented next
to the heading ‘Addendum’, including the date and time of the omitted event and the
date and time of the addendum.
For hardcopy records, addendums must be appropriately integrated within the record
and not documented on additional papers and / or attached to existing forms.
 s) Written in error - all errors are must be appropriately corrected.

No alteration and correction of records is to render information in the records illegible.

An original incorrect entry must remain readable ie. Do not overwrite incorrect entries, do not
use correction fluid. An accepted method of correction is to draw a line through the
incorrect entry or ‘strikethrough’ text in electronic records; document “written in error”,
followed by the author’s printed name, signature, designation and date / time of correction.

For electronic records the history of audited changes must be retained and the replacement
note linked to the note flagged as “written in error”. This provides the viewer with both the
erroneous record and the corrected record.

Documentation by nurses and midwives

Documentation by nurses and midwives must include the following:
a) Care / treatment plan, including risk assessments with associated interventions.
b) Comprehensive completion of all patient / client care forms.
c) Any significant change in the patient / client’s status with the onset of new signs and
symptoms recorded.
d) If a change in the patient / client’s status has been reported to the responsible
medical practitioner documentation of the name of the medical practitioner and the
date and time that the change was reported to him / her.
e) Documentation of medication orders received verbally, by telephone / electronic
communication including the prescriber’s name, designation and date / time.

Abbreviations, Acronyms, Symbols, and Safety

The Joint Commission has endorsed the Institute for Safe Medication Practices List of Error-Prone
Abbreviations. The ISMP list is also endorsed by the Federal Drug Administration (FDA), and the
National Council for Medication Error Reporting and Prevention (NCCMERP).

The ISMP List of Error-Prone Abbreviations includes a large number of abbreviations,

including:
• U,u
• IU
• Q.D., QD, q.d., qd
• Q.O.D., QOD, q.o.d, qod
• Trailing zero (X.0 mg)
• Lack of leading zero (.X mg)
• MS
• MSO4
• MgSO4

A trailing zero may be used only when required to demonstrate the level of precision of the value
being reported, such as for laboratory results, imaging studies that report the size of lesions, or
catheter/tube sizes. It may not be used in medication orders or other medication-related
documentation
Consider the following as a "Do Use" list:
• Use mL instead of cc.
• Write out the word: unit.
 • Use mcg instead of: μ.
• Use less than and greater than instead of < and >.

Quality Nursing Documentation: Over and Above Requirements

Quality Nursing Documentation:

1. Centers on the patient. Documentation reflects the patient’s concerns, responses, and
perspective and does not simply list nursing tasks accomplished.
2. Reflects the actual work of nurses. Includes education, psychological support, and other
nursing care for patients that are often passed among nurses orally, but never documented.
3. Reflects the objective clinical judgment of nurses. Describes findings and reaches
conclusions, that is, not “appears” or “seems,” but reports data and conclusions.
4. Proceeds in a logical and sequential manner, especially when evaluating a problem.
5. Is recorded concurrently with events.
6. Records variances in findings and in care. Does not duplicate information to be found in
other parts of the record. Does not list tasks.
7. Fulfills legal requirements.

Dangers of Charting in Advance

Certain situations may tempt nurses to chart in advance:
• Flow sheets used in conjunction with charting-by-exception documentation systems.
• Protocols that mandate frequent assessment and documentation, such as neuro checks
and patients in restraints.
• The sponge count in the OR. One of the most dangerous charting practices in the OR is
the notation, “sponge count done and correct” before the operation is over and the
sponge count has, indeed, been done. This practice carries with it many liabilities. Most
obviously, it raises the issue of whether the count was ever done.
• Medication administration records. Some nurses have the dangerous habit of charting
medications in advance. This practice places the patient at risk because it misrepresents
the current medication profile of medications the patient has on board. If for whatever
reason a medication is not given after a nurse has charted it as given, the nurse has
falsified the record.

Late Entries
When the medical record is unavailable or when you remember further information to
document, you will need to make a late entry. Document the time of your entry. Within the
body of your note indicate the time of the occurrence to which you are referring.
However, entering pertinent information is better done late than never. Shorter lengths of stay
on inpatient units may increase the likelihood of the need for late entries. Follow your
organization’s policy for making late entries.
The safest, most legally defensible practice is to document at frequent intervals, and particularly
after any emergency, unusual, or complicated events. When you absolutely cannot do so,
make notes and document carefully into the medical record at your earliest opportunity.

Correcting a Documentation Error

The most widely accepted procedure for correcting errors has been to draw a single line through
error and note “mistaken entry,” “error,” or the error notation that is required by your
organization, followed by the date and your initials. Since your signature follows the original entry,
your initials are sufficient unless organizational policy requires otherwise.

HOWEVER, consult your organization’s policy regarding correction of errors. Some organizations
have discontinued and prohibited the use of the terms “error” or “mistake” because of the possible
interpretation that an error occurred in patient care and not simply in making a documentation
entry.

Never erase an entry or use correction fluid, liquid paper, or “white out.” If you need to replace
several words, you may need to add an addendum sheet and follow the procedure for late entries.

Frequency of documentation
The frequency of documentation entries should conform to the following as minimum
requirements.

Acute Care Patient / clients

a) Registered Nurse / Midwife, Enrolled / Endorsed Nurse should make an entry in the patient /
client’s health care record a minimum of once a shift. An entry by an Assistant in
Nursing should not be the only entry for a shift.
Entries should reflect in a timely way the level of assessment and intervention. The results
of significant diagnostic investigations and significant changes to the patient / client’s
condition and/or treatment should be documented as these occur.
b) Medical practitioners should make an entry in the health care record at the time of events,
or as soon as possible afterwards, including when reviewing the patient / client.7
c) Other health care personnel should make entries to reflect their level of assessment and
intervention consistent with the medical management plan.

Long Stay or Residential Patients / Clients

Depending on the health care setting and the length of stay (or expected length of stay) of
the patient / client, health care personnel should make an entry at least weekly in the health care
record particularly when warranted by the patient’s medical condition or frailty. Additional entries
should be made to reflect changes in the patient / client status, condition and/or treatment or care
plan as these occur.

Non-Admitted Patient / Clients

An entry must be made in the health care record for each patient / client attendance
(including video conference sessions) and for failures to attend.
Entries should reflect the level of assessment and intervention. The results of significant
diagnostic investigations and significant changes to the patient / client’s condition and/or
treatment should be documented.
Attendance of individual patient / clients at sessions of a formal multiple session group
program should be noted. Such attendances may be documented in an attendance register or
scheduling system rather than the patient / client’s health care record. Where a patient / client
receives specific individual care or treatment in addition to the group session interaction, this care
or treatment should be documented in their health care record.

Alerts and allergies

 Clinicians must flag issues that require particular attention or pose a threat to the patient /
client, staff or others including:
a) Allergies / sensitivities or adverse reactions, and the known consequence.
b) Infection prevention and control risks.
c) Behaviour issues that may pose a risk to themselves or others.
d) Child protection / well-being matters including
i. alerts and flags for High Risk Birth Alerts or prenatal reports
ii. Children at risk of significant harm
iii. Where NSW Police or the Department of Family and Community Services have issued a
general alert to a PHO.
e) Where patients / clients have similar names and other demographic details.

Labels
Non-permanent adhesive labels should be avoided. Where considered essential the label
must be relevant to the patient / client and placed so that all parts of the health care record are
able to be read and patient / client privacy maintained.

Tests – requests and results

The health care record must document pathology, radiology and other tests ordered, the
indication and the result. When tests are ordered the name of the ordering medical practitioner
/ approved clinician and their contact number must be clearly printed (if written) or entered (if
computerized) on the request form.
Pathology, radiology and other test results must be followed up and reviewed with notation as
to action required. The results must be endorsed by the receiving medical practitioner /
approved clinician, with endorsement involving the name, signature, designation of the medical
practitioner or approved clinician, and date / time.

PHOs must develop local procedures, including steps to be taken, when:

a) Relevant details on the request form are incomplete or illegible.
b) The ordering medical practitioner / approved clinician is not on duty or contactable.
Critical/unexpected/abnormal results should be documented in the patient / client’s health care
record by the responsible medical practitioner / approved clinician as soon as practicable and
any resultant change in care / treatment plans documented.

Anaesthetic reports

Anaesthetic reports must include the following:

a) Pre-operative assessment, including patient anaesthetic history.
b) Risk-rating eg. American Society of Anaesthesiologists (ASA) score.
c) Date and time anaesthetic commenced and completed.
d) Anaesthesia information and management ie. medications, gases, type of anaesthetic.
e) NSW safety checklists including patient assessment and equipment checklists consistent
with Australian and New Zealand College of Anaesthetists requirements.
f) Operative note / monitor results.
g) Post-operative notes / orders.

Operation / procedure reports

Operation / procedure reports must include the following:
a) Date of operation / procedure.
 b) Pre-operative and post-operative diagnosis.
c) Indication for operation / procedure.
d) Procedure safety checklist.
e) Surgical operation / procedure performed.
f) Personnel involved in performing the operation / procedure.
g) Outline of the method of surgery / procedure.
h) Product / device inserted and batch number.
i) Changes to, or deviations from, the planned operation / procedure, including any adverse
events that occurred.
j) Operative / procedural findings.
k) Tissue removed.
l) Pathology ordered on specimens.
m) Post-operative orders.

Leaving against medical advice

A patient/client who decides to leave the health service/program against medical advice must be
asked to sign a form to that effect with the form filed in the patient/client’s health care record. If
the patient/client refuses to sign the form this must be documented in the health care record,
including any advice provided.
References:

Ministry of Health, NSW, 2017. “Health Care Records - Documentation and Management”. 73 Miller
Street North Sydney NSW 2060. Retrieved from http://www.health.nsw.gov.au/policies/

Department of Health, 1994. “Hospital Medical Records Management Manual”. San Lazaro
Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Second Edition.

Case Di Leonardi, Bette. June 1, 2012. “Professional Documentation: Safe, Effective, and Legal”
Copyright © 2009 by RN.com

The Joint Commission (TJC). (2012a). Hospital National Patient Safety Goals effective January 1,
2012. Oakbrook, IL: TJC. Retrieved from http://www.jointcommission.org/assets/1/6/NPSG_
Chapter_Jan2012_HAP.pdf

American Nurses Association (2010b) ANA’s principles for nursing documentation: Guidance for
Registered Nurses. Silver Spring, MD: ANA, Nursebooks.org.