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Documentation


Documentation is communication. As such, the medical record should provide sufficient information for team members.
  • Use standard abbreviations.
  • Convey the degree of urgency of an order.
  • Keep your writing legible.

Sufficient information should appear in the medical record to enable all team members to understand the patient's history, physical findings, diagnosis and rationale for the diagnosis, and the treatment and care plan.

Patient care orders and prescriptions should convey the appropriate degree of urgency. Orders can include triggers to communicate. For example, a certain change in a patient's vital signs (e.g. a particular temperature) should trigger notification of the physician.

Legibility is important. Illegible writing has resulted in many adverse events (accidents in Québec). Words may be printed if necessary. Only standard abbreviations should be used.

Reviewing notes from others

Nurses and other healthcare professionals are trained to document their observations. Physicians should take care to review such documentation.

Explore an eLearning activity on Documentation: charting medical records. Opens in new window
A Statement of Completion or CME credits are available.