The management of medical records, including content and organization, should be consistent throughout an organization and consistent within each discipline. Organizational policies and procedures should outline the general rules for the medical professional regarding documentation. Additionally, the records should be organized so that individual pieces of information are easy to locate within the record as a whole. Therefore, all records in the same facility should be organized the same way whether they are hard copy or electronic.
Documentation should reflect how the patient/client arrived at your facility, for example self referred, physician referred or prescribed or physician extender. A non-physician practitioner (NPP) such as an advanced registered nurse practitioner (ARNP) or physician assistant (PA), or other—should be included in the patient's medical record. If the patient/client comes with a written order, that order becomes part of the record. If referred by telephone or verbal order, the person that took the order must transcribe it, consistent with state law and facility policy. The transcription of the referral should also be followed up by a signed written referral, preferably an original rather than a fax.
Records must be kept in locked, fireproof storage and must be accessible only to those directly involved with the patient/client. Electronic records must be password coded and screens must be shielded from public view. Security measures, such as firewalls, should also be in place.
In facilities that use manual entry, there should be a single, hard copy “chart.” If manila file folders are used, it is best practice to use a new folder for each new patient/client. If it is policy of the facility to reuse folders, all references on and in the folder to the prior patients/clients should be obliterated for privacy purposes. If records are maintained electronically, there should be separate electronic charts for each patient/client clearly identified.
For those organizations using manual entry, only ink should be used, preferably black or blue. In the recent past, black was generally expected and required. With the advent of improved copying systems, it can be difficult to discern an original from a copy. Therefore, from a legal perspective, some organizations have changed to blue ink. However, this is a decision for the organization or individual practitioner. There should be consistency in color within the practice as outlined in a policy. Generally, black ink is still the preferred color used for manual medical entries.
All entries must be legible to anyone who may need record access. Illegibility may give the impression of carelessness and rushed efforts. For electronic records, consistent font style and size should be used. Some electronic systems allow manual entry. In these systems, entries must be legible. Legibility also refers to signatures. As most signatures are not legible, it is critical that all licensed professionals use their state license numbers following their names so they can be identified. In the case of ...