The Basics of Medical Record-Keeping Documentation
Jeannine LeCompte, Compliance Research Specialist
Many problems which arise as the result of incorrect medical record-keeping can be prevented by following easy-to-remember procedures, such as the “Four Ws” and the “PROGRESS” plan.
The “Four Ws” are as follows:
- “What”— Make sure that what is happening to the patient is fully documented. This includes all changes in medical condition; behaviors, and accidents or incidents; all care plan interventions; and new medical orders.
- “Where”—Ensure that all progress notes, care plans, and assessments are logged in full.
- “When”—An entry must be made as soon as a problem is identified. This can be a short descriptive phase describing, for example, a report of pain from a patient, or a request for specific treatment, or to see a physician.
- “Why”—The entry must be made with the understanding that “if it is not documented, it did not happen”—and therefore, everything, no matter how inconsequential it might seem to staff at the time, must be written up.
The “PROGRESS” procedure provides a handy guideline for the process of preparing the records:
“P”— Plan what you are going to say;
“R”—Review recent disciplinary notes to identify other entries that need to be addressed;
“O”— Objective facts only: don’t share opinions or rationalize;
“G”— Grammar, spelling, and abbreviations need to be checked;
“R”— Repetition: avoid repeating identical documentation over and over with no new content;
“E”— Exception: chart on abnormal occurrences or findings only;
“S”— Sequential: ensure that notes about an issue appear in proper sequence and are identified in real time;
“S”— Sign and date all entries and use your professional credentials.
A failure to follow these simple rules can hinder other disciplines from acquiring important information needed to diagnose and treat a patient. It can also lead to delays in care implementation, and, equally important from the facility’s side, might cause a failure to provide support for reimbursement for care provided.
Following the steps outlined above can provide an important level of protection should there be a later legal dispute. The absence of comprehensive records can render a facility vulnerable to charges of negligence and failure to care, and place the responsible staff in a highly vulnerable situation, even if they have provided all the care required—because “if it was not documented, it did not happen.”
