Chapter 4: Rules of Charting Flashcards
What is the first rule of Charting?
Make sure the electronic health record correctly matches the patient.
What is the second rule of Charting?
Keyboard accurately.
What is the third rule of Charting?
Be as specific as you can.
What is the fourth rule of Charting?
Leave no blank lines or spaces, Begin your chart entry on the next available line.
What is the fifth rule of Charting?
Do not erase, overstrike or delete any entry (A medial record is a legal document and should never be altered).
What happens when there is a need to change a patient record?
Write an addendum with the date of the revision.
What is the sixth rule of Charting?
Document the information in a timely fashion. Charting should occur immediately after treatment while details are still fresh.
What is the seventh rule of Charting?
An e-signature event captures and displays the author’s name, credentials, date and time of application. Once electronically signed, the system prevents deletion or alteration of the entry and its related electrons signature for the life of the referenced documentation.
What is the eighth rule of Charting?
Do not document irrelevant information; only chart the facts.
What is the ninth rule of Charting?
Avoid sarcasm, criticism, humor, and profanity.
What is the tenth rule of Charting?
Keep abbreviations to a minimum and use only standard abbreviations.
