Policy Manual sample

MDT Home Health Care Agency, Inc. LEGAL ASPECTS OF CHARTING/REPORTING CLIENT’S STATUS PURPOSE: To provide a legible and descriptive legal document. POLICY: The Director of Nursing, Clinical Manager will assume responsibility for the consultation on monitoring the legal aspects of the medical record. PROCEDURE: l. ALL charting must be legible and written in black ink. 2. ALL charting must be dated, timed and signed. 3. Document pertinent facts about the patient in the nurses' clinical notes. 4. Document routine elements of care that do not relate to identified problems in the spaces provided for this purpose (see Patient Progress Record). 5. Use only the approved standard abbreviations. 6. Make appropriate correction for changing errors: a. Draw one line through error entry so it can still be read. b. Write "error" above the error, and then note correct entry in the chart. c. Never use White Out or destroy any portion of the chart. 7. Always document the following: a. Nursing actions taken. b. Medical orders completed. c. Patient responses to statement. d. Patient understanding of illness, treatment, etc. e. Available information which relates to identified problems. f. Client’s status, problems, and situations. 8. Never leave open space (lines) between changing entries. Entries in the patient record are authenticated by the author. Information introduced into the patient record through transcription or dictation is authenticated by the author. Note 1: Authentication can be verified through electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key. Note 2: For paper-based records, signatures entered for purposes of authentication after transcription or for verbal orders are dated when required. For electronic records, electronic signatures will be date-stamped. Home Health Agency Nursing Manual J-9