Dos and Don’ts For Summarizing Medical Records

Learn the essential guidelines for summarizing medical records effectively and accurately. Discover the do’s and don’ts to ensure your documentation stands up in a negligence lawsuit and maintains its integrity.

Accurate and well-organized summarization of medical records can play a crucial role in defending yourself in a negligence lawsuit and even help you avoid court altogether. It is vital to ensure that your summaries are comprehensive, updated, and timely. Failing to do so may result in them being used against you in legal proceedings.

To assist you in this process, here are some important do’s and don’ts to keep in mind:

Do’s:

1. Ensure Current Information: Before you begin writing, verify that you have the correct chart. Your documentation should accurately reflect the nursing process and your professional expertise.

2. Include Clinically Pertinent Information: The medical record serves as a primary means of continuity and communication among all healthcare providers involved in a patient’s care.

3. Record Follow-Up Plans: Document any precautions, preventive measures, or interventions employed, such as the use of bed rails. Include details of each phone call made to a physician, noting the exact time, message, and response.

4. Handle Conflicting Data: If you remember an important point after completing your documentation, add it as a “late entry.” Clearly indicate the date and time of the late entry. Document frequently enough to convey the complete narrative.

5. Write Legibly: Ensure that your patient summaries are written clearly and can be easily read and understood.

6. Document Medication: Note any instances of a patient refusing treatment or medication and record the time you administered medications along with the patient’s response.

Don’ts:

1. Avoid Altering Patient Records: Tampering with patient records is a criminal offense and should never be done under any circumstances.

2. Refrain from Using Uncommon Abbreviations or Shorthand: Stick to widely accepted abbreviations and avoid using shorthand that may be unclear or unfamiliar to others.

3. Avoid Imprecise Descriptions: Your documentation should provide clear and accurate descriptions of events, symptoms, and observations.

4. Don’t Attribute Statements or Sensations to Others Without Proper Attribution: Unless it is essential, refrain from documenting what another person said, heard, felt, or noticed. If necessary, use quotes and attribute the comments accurately.

5. Do Not Chart Care in Advance: Avoid documenting care that has not been provided yet, as unforeseen circumstances may prevent you from delivering the planned care. Documenting unperformed care is considered fraudulent.

6. Do Not Include Incident Reports or Legal Service Referrals in Medical Records: Filing incident reports or referring to legal services should not be documented within the medical record.

In conclusion, the accurate summarization of medical records is crucial in various legal and healthcare contexts. If you require assistance with this process or have any questions, our experienced team at ITCube BPO is ready to help. Feel free to contact us at info@itcubebpo.com or call us at +1 (210) 876–0967. We have over a decade of expertise in healthcare record management.