Dos and Don’ts for Medical Records Summarization

Dos and Don’ts for Medical Records Summarization

Good summarization of records can enable you to defend yourself in a negligence lawsuit, and it can likewise keep you out of court in any case. You need to ensure that it is total, amended, and convenient. In case it's not, it could be utilized against you in a lawsuit.

 Here is list of the Dos and Don'ts you need to remember the while summarization of medical records. 

Let Us Go Through Some Dos:

•  The Most Current Information:  Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities.

• Clinically Pertinent Information: The medical record is a primary mechanism for providing continuity and communication among all practitioners involved in a patient's care.

•  Follow-Up Plans: Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.

• Handling Conflicting Data: If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

• Write legibly: Make document summary of patient, which is capable of being read or deciphered especially with ease.

• Medication: Mentioned a patient's refusal to allow a treatment or take a medication and also chart the time you gave a medication and the patient's response.

Let Us Go Through Some Don’ts:

• Don't alter a patient's record--this is a criminal offense.

•  Don't use shorthand or abbreviations that aren't widely accepted.

• Don't write imprecise descriptions.

• Don't to diagram for what another person stated, listened, felt, or noticed unless the information is critical. In that case, utilize quotations and characterize the comments properly.

• Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

•  Don't include the filing of incident reports or referrals to legal services.

Final Words:

Our expert team at ITCube BPO has a wealth of experience in the healthcare record management industry over a decade. We hope our advice is helpful to you. 

If you feel that you need more support with the process or you have any questions for us, please feel free to contact us on info@itcubebpo.com or you can call us on +1 (614) 434-2376