Dos and Don'ts in Medical Record Charting

1. ALL ENTRIES in medical records must be LEGIBLE, DATED AND SIGNED including their professional title and IDENTIFICATION so that any future reader can identify each entry's author.

2. Avoid using problem prone abbreviations listed in Table I below. Do not use abbreviations Use only abbreviations and symbols approved by your medical office, clinic, or hospital.

3. Use only approved chart forms with the patient's name, the date, and the time recorded on each sheet and on, if applicable, both sides of every sheet in the record.

4. Use ink; never pencil.

5. Don't skip lines or leave spaces between entries.

6. Don't use vague, non-descriptive terms.

7. Don't get personal. Comments cannot be removed or changed. Refrain from entering into the chart any statement that does not deal directly with the patient's diagnosis, treatment, care or condition.

8. Don't use the medical record to comment on other health-care professionals or their actions.

9. Don't wait until the end of the day to chart.

10. Don't back date, add to or tamper with notes on the medical record.

11. Don't use terms unless medical assistants know what they mean.

12. Always legibly identify yourself by signature, or initials.

13. All entries in the medical record must be signed by the author. Federal law mandates that only the author can sign his/her entries in medical records.

Abbreviation to Avoid	Intended Meaning	Misinterpretation	Correction
D/C	discharge discontinue	Premature discontinuation of medication (intended to mean discharge) especially when followed by a list of discharge medications.	Use "discharge" and "discontinue"
MgSO4	Magnesium sulfate	Morphine sulfate
MSO4	Morphine sulfate	Magnesium sulfate
MTX	Methotrexate	Mitoxantrone
ZnSO4	Zinc sulfate	Morphine sulfate
q.d. or QD	every day	Mistaken as q.i.d. especially if the period after the "q" or the tail of the "q" is misunderstood as an "I".	Use "daily" or "every day" If abbreviation is used, capitalize and avoid use of periods.
q.o.d. or QOD	every other day	Misinterpreted as "qd"(daily) or "qid" (four times daily) if the "o" is poorly written	Use "every other day". If abbreviation is used, capitalize and avoid use of periods.
U or u	units	Read as zero (0) or a four (4) causing a 10-fold overdose or greater (4U seen as "40" or 4u seen as "44").	Unit has no acceptable abbreviations. Use "unit".
IU	international units	Misread as IV (intravenous)	Use "units"
TIW	three times a week	Mistaken as "three times a day"	Spell out "three times a week"
AU	each ear	Mistaken for OU "each eye"
SS	sliding scale (insulin) mistaken	for "55"	Spell out "sliding scale"
Zero after decimal point 1.0 (trailing zero)	1 mg	Mistaken as 10 mg if the decimal point is not seen	Do not use trailing zero's
No zero before a decimal dose .5 mg (no leading zero)	0.5 mg	Misread as 5 mg	Always use zero before a decimal when the dose is less than a whole unit

LEARNING TIP FOR NEW MEDICAL ASSISTANTS AND NURSING STUDENTS: SEEK PRACTICE

SCENARIOS for PRACTICE CHARTING (both medical office and phone call situations)!