KIN 2500 Chapter : Documenting In Medical Chart
15 Mar 2019
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Proper documentation in medical records is a required skill needed by registered dietitians. Guidelines for proper documentation: medical records are permanent legal documents. All entries should be written in black pen or typewritten only: documentation should be complete, clear, concise, legible and accurate, entries should be documented by service, date, and time. Complete sentences are not necessary, but grammar and spelling should be correct: abbreviations with multiple meanings should be avoided. Institutions usually have approved list of abbreviations: all entries must be signed at the end of the chart note, no one should ever chart or sign the medical record for another person, charting must be objective, be specific. Many words have different meanings: never comment or criticize others opinions or protocol in a chart, documentation should be done at the time of the actual procedure or service. Using soap notes for documentation of nutritional assessment:
