The organization must define and implement a procedure for the accurate and timely entry of all information into patient medical records. This procedure shall ensure that all required documentation is completed as close to the time of service as possible, while maintaining patient privacy and data integrity.
This procedure should specifically address the inclusion of the following elements:
- Patient identity: accurate and verified information.
- Clinical history: comprehensive account of the patient’s health, including past illnesses, medications, allergies, and care background.
- Assessments and diagnoses: clinician's findings and official diagnoses.
- Treatment plan: proposed and executed treatments, procedures, and interventions.
- Patient communication: all information and instructions provided to the patient, as well as evidence of informed consent for treatments.
- Attributions and authenticity: the identity and signature (or electronic equivalent) of the healthcare professional responsible for the entry.
- Disclosures: details of any disclosures of information, including to whom, when, and for what purpose.
The procedure shall include clear quality control measures and auditing processes to verify that entries are complete, accurate, and made in a timely manner.
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