9 Tips for Writing Rock-Solid Medical Charts

Does anyone else out there get tired of paperwork? From time to time, when I get a bit burnt out, work one too many nights shifts, or am simply feeling a bit on the lazy side, the paperwork associated with my work as a nurse practitioner can seem overwhelming. There are prescriptions to write, work notes to sign, and labs to review, not to mention completing charts for patients I see throughout the day.

While most of these ‘paperwork’ tasks have recently become electronic, I find the ‘computer work’, if you will, to be equally exhausting. When these feelings of frustration grow, or the clinic or hospital gets busy, charting is often the first thing nurse practitioners let slide. As pressure in our practices mounts throughout the day, we being to set charts aside to complete later, write sloppily, or abbreviate our documentation. Even with electronic medical records charting can suffer. But, cutting corners in your medical charts can have serious consequences.

Medical charts serve many important purposes and not giving them proper attention is a big mistake. First and foremost, if you are ever faced with a malpractice suit, your medical chart is the first place attorneys will look for answers. Besides keeping you out of legal trouble, your documentation is also the basis for how you are paid by insurance companies. If your charts aren’t complete, you may not be earning to your full potential. Finally, solid medical charts are essential for continuity of care. Patients often see multiple providers and creating a thorough medical record helps other providers know what you have done for a patient and understand the reasoning behind these actions.

So, how do you make sure your documentation is rock solid? These tips will help.

1. Keep it legible and professional

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If you still use paper charts, legibility is a big issue.  It can have a significant impact on how much you are paid. Any portion of a chart that can’t be read will likely be disregarded. Not to mention, illegible charts are not as useful in protecting you should a liability issue arise.

When you use abbreviations in your charting, make sure they are universally accepted and not your own shorthand. Abbreviations are an appropriate way to chart more efficiently, but you must follow professional and institutional standards to avoid confusion. “PE”, for example, can stand for pulmonary embolism, pleural effusion, or pulmonary edema. Most institutions have a list of accepted abbreviations you can pull from.

2. Beware of EMR laziness

Electronic medical record (EMR) systems make it all too easy to mindlessly click through a patient’s chart to completion. Most EMR programs have setting that allows providers to automatically select and chart normal parameters. While these settings help with your charting efficiency, they can be a major pitfall. Make sure you don’t inadvertently mark something as normal when it was not. Use narrative throughout your chart to show you were deliberately selecting information. 

3. It’s all about cause and effect

Whenever you chart a patient complaint, it must be addressed later in your chart. If the patient presents with multiple complaints, make sure you carry the history, exam findings, diagnosis and plan for each one through the chart.  While you will, of course, focus primarily on the main complaint during the visit and in your chart, a complete chart should address each issue.

4. Stop procrastinating

Completing your charts as you go throughout the work day, as close to the actual patient encounter as possible, is to your benefit. This way, details will be fresher making sure you document as completely and accurately as possible. And, you won’t have to dread facing a pile of paperwork at 5 o’clock each afternoon. 

5. Get consent and document it

Procedures can be a risk when it comes to liability in your practice. By law, informed consent is required before performing a procedure. Don’t forget to have your patient sign a consent form which includes all risks of the particular procedure and include it in the chart.

Procedure notes should also be carefully documented so your chart proves that a standard of care was met. Rather than using words like “complicated” in your documentation, be specific about how you arrived at this determination. Include measurements when possible as this helps coders charge appropriately for your services.

6. Be complete and specific

You must carefully document each step of the patient’s visit recording not only the patient’s complaint and history but also the actions you take as a provider. If you look at the patient’s past medical history, for example, note this in the patient’s chart. As part of documenting each step of your interaction with a patient be as specific as possible about what took place. Using direct quotes from patients, for example, helps make your documentation solid if the details of the visit ever come into question.

7. Document refusal of care and noncompliance

If you recommend a test or treatment to a patient and they decline, write it down. Patients certainly have the right to refuse your suggestions for their care, but make sure to note your recommendations as well as the date and time of refusal. Should the patient suffer a negative outcome, this helps protects you legally.

8. Include follow-up instructions

Follow-up care is a largely neglected area in medical documentation. It can be time consuming to note the specific precautions and recommendations you give a patient, but documenting a plan for follow-up care is essential. Even if your patient is negligent in follow-up care, juries hold medical providers to higher standards than patients. If you haven’t clearly documented guidelines for follow-up, you could suffer legal consequences.

Keeping a copy of follow-up instructions given to the patient will further boost your documentation. Make sure your instructions are specific, for example “follow up for a temperature greater than 100.4” rather than “follow up for a fever”. Document additional calls you make to or calls you receive from the patient as well as any lab results that return once the patient leaves the clinic or hospital.

9. Make changes with caution

Medical records are legal documents and altering them inappropriately can land you in big trouble. If you find an error in a chart, draw a single line through it keeping the original entry legible. Electronic medical records often note changes that are made so use the same principle with EMR systems. Keep the original and corrected entry noting the reason for the change. If you forgot to include something in your chart, document it as an addendum with the time and date of the change.

Remember, if you don’t record something in a patient’s medical record, it didn’t happen. Not only does proper documentation protect you from legal trouble, it also serves the best interest of your patients and makes sure you get paid for the work you do. Spending a little extra time up front to document neatly, carefully, and completely could save you time and a major headache in the future.


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