General Documentation

ARE THERE ANY GUIDELINES FOR UNLICENSED HEALTHCARE PERSONNEL’S DOCUMENTATION IN THE MEDICAL RECORD? Curi’s Best Risk Advice on General Documentation Thorough, clear, accurate, objective documentation facilitates continuity of patient care and can improve patient outcomes. The medical record is a legal document. It is your primary defense tool in the event of a malpractice lawsuit. It is important that all entries into the record follow established guidelines for good documentation practices. Unlicensed healthcare personnel (UHP) may be unfamiliar with these rules; therefore, proper training is required. The following are medical record documentation guidelines for ALL medical staff including UHP: Documentation should be complete, concise, and factual. The third person tense (he, she, it, etc.) should be used when writing entries. Please be mindful to use a patient’s preferred pronouns. Appropriate medical terminology and abbreviations should be used. Entries must be free of ed...