Question

Most medical offices now use EMR in which case, creating a paper chart would not be necessary. Tell me how you would properly organize a patient's physical medical chart according to office guidelines.

Answer 1

# ACCURATE patient ID number and name on each record . Author identification should be handwirtten signature or electronically noted with initials on each record.

# Each record should be dated, keep confidentiality, all history of allergies, medication reactions should be noted. Laboratory values should be clear.

# Diagnosis,planning, treatment modalities and prognosis should be consistent and accurate. There should not be overwriting in records.

# Organize all records and reports in chronological manner. List all the past medical history,surgical history, previously used medications, and fanily history. Keep a copy of all records and up to date. Keep accurate chart of phone orders according to organization policy.

# Chart should not be teared, misplaced or loose labels. Update EMR as well . Draw a single line through the entry,document error and correct info with date, time and initials. Should be written in a scientific manner, legible and relevant.