Sign, Date and Time All Medical Record Entries
All entries in medical record documentation must be signed, dated and timed. All hand-written notes start with the date at the top of the entry and end with a clinician’s signature, date, time and pager number.
This is necessary to ensure patients receive the highest quality health care, and it’s a new requirement of The Joint Commission. The unannounced Joint Commission accreditation survey of BWH will occur at any time between now and May 2010.
If you are using the LMR to create inpatient documentation, you are required to sign the note electronically, print it and place in the medical record. Remember: LMR draft notes should not be placed in the inpatient medical record. LMR draft notes were designed as ambulatory notes viewable only by the author.
Here are other tips that will help you navigate medical record documentation:
When using a word template to create inpatient documentation, you are required to print the document, sign it by hand (include date and time) and place the document in the medical record.
If you are using copy and paste to carry information forward to a new note please be sure you are using the correct patient information and not that of another patient.
Be sure that the notes you are printing are legible. If the printer is low on toner, please resolve and reprint the note.
Sharpie markers should not be used for documentation. Ink usually shows through on the other side of the paper, making it difficult to read.
Patients being discharged and transferred to another facility require a completed discharge summary prior to the transfer.
Find more useful tips on the upcoming Joint Commission unannounced visit on BWHPikeNotes’ Readiness Central. Any questions? Contact Marcy Carty, MD, MPH, or Jackie Raymond.