Julie Banas

HLTH 1010
Assignment 6.2

Charting Principles
DO

Chart submission promptly (Klingman, 2010)

Always sign submissions with first name, last name, and professional status (Klingman,
2010)
Chart using exact times (Klingman, 2010)
Be objective and provide facts (Tilton, 2015)
Charts need to include a unique identifier, patient name, and DOB on every page of the
health document (Medical Board of Australia, Dec 2012)
Use 24-hour clock time when documenting time (Medical Board of Australia, Dec 2012)
Use legible writing, written in English (Medical Board of Australia, Dec 2012)
Late entry submissions should be identified as such and have date and time of entry and
reference to date of event (Hays, K., 2011)
Entries should be kept objective (Hays, K., 2011)
Charting should include a plan of care noting recommended course of treatment (Tharpe,
2006)
Elements in a clients medical records should be organized in a consistent manner
(Tharpe, 2006)
Document all relevant information including normal findings (Indest, G. F., & Patrou, J.,
2008)
Error corrections should be done with a line drawn through the erroneous information
with a date at the end of the line (Hays, K., 2011)

AVOID

Avoid use of abbreviations and symbols when possible (Lockwood, 2015)

Avoid us of subjective terms; tired, angry, confused, rude, happy, (Lockwood, 2015)
Never chart an entry in advance (Lockwood, 2015)
Avoid removing parts of the charts to work on elsewhere (Tilton, 2015)
Avoid drawing conclusions (Tilton, 2015)
Never alter a chart to remove information (Hays, K., 2011)
Records should not be stored in a manner in which their safety and confidentiality are at
risk (Tharpe, 2006)
Avoid criticism (Tilton, 2015)
Avoid defensive charting after an incident has occurred (Indest, G. F., & Patrou, J., 2008)
Do not use any part of a clients chart for personal use (Indest, G. F., & Patrou, J., 2008)
Avoid slang or non-standard terms in charting (Lookwood, 2015)
Avoid leaving blank spaces in the chart (Lookwood, 2015)

Julie Banas
HLTH 1010
Assignment 6.2

References
Hays, K. (2011, May 6). The midwifes story: Youre your chart reflect who you really are.
Midwives Association of Washington State (MAWS) Spring Conference. Retrieved
October 02, 2016, from http://www.washingtonmidwives.org/documents/Karen-HaysCharting.pdf
Indest, G. F., & Patrou, J. (2008). The Florida nursing law manual. Altamonte Springs, FL:
Nursing Law Manual.
Klingman, L., MSN, RN. (2010). Defensive Documentation: Avoiding Malpractice. Retrieved
October 02, 2016, from http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Documentation
Avoiding Malpractice 2010.pdf
Lockwood, W. (2015, March). Documentation: Accurate and legal. Retrieved October 2, 2016,
from http://www.rn.org/courses/coursematerial-66.pdf
Medical Board of Australia (Dec 2012). Health records- Documentation and management.Good
MedicalPractice: A Code of Conduct. PD_2012_069. Ministry of Health, NSW73 Miller
Street North Sydney NSW 2060 Retrieved October 2, 2016, from
http://www0.health.nsw.gov.au/policies/pd/2012/pdf/PD2012_069.pdf
Tilton, D., Tilton, S. (2015, Oct 2). Medical documentation. CEUFast.com, Nursing CE.
Retrieved October 2, 2016, from https://ceufast.com/course/medical-documentation
Tharpe, N. (2006). 2006-2009 clinical practice guidelines for midwifery & women's health.
Sudbury (Mass.): Jones and Bartlett.