How to Write a Medical Chart

Write legibly when recording any information on a medical chart.

A medical chart provides communication among the health care professionals about a patient's health and care experience. The purpose of this chart is to serve as a medical and legal record, according to eNotes. As a medical record, the chart provides information on the patient's health, including admission, treatments and responses. As a legal record, the medical chart provides evidence of the patient's care experience. Health care professionals must enter this information clearly and concisely when writing in the medical chart.

Instructions

1. Write the date and time on all patient encounters. This includes admission, medication, surgery and treatments.

2. Write the patient's full name. Include any other identifiers such as the patient's date of birth or a medical record number.

3. Write the medical record in chronological order. Do not leave out any information that is pertinent to the patient's care.

4. Record any statements made by the patient or others in quotes. Always use the current time and date with documentation.

5. Document any occurrences that may affect the patient. This evidence may be necessary in a court case. The court considers information not documented as questionable.

6. Write objectively, instead of subjectively. Explain if the patient was hostile toward the physician or staff without using derogatory or judgmental language.

7. Cross out any errors. Draw one line through the word and write the correct word. Insert your name and the current date after you made the proper correction.

Tips & Warnings

• Use blue or black ink when writing in a medical chart.

• Do not use abbreviations or unclear penmanship.

• Never leave a medical chart in an open area where others could read it or edit it.

References

• enotes.com: Medical Chart
• Duke University Medical Center: How to write progress notes and communicate in medical charts