| IMPORTANT
UPDATE
PLEASE READ.... | | An update to your HM Composite Dietitian Procedure Manual, page 21 "HM Composite Guidelines for Medical Records Etiquette" is available here. Please read it, and print and replace the page in your staff binder. Sign this form indicating you have read it, and fax or send to our office for your personnel file.
*You can also access the Update and Form on the HMC Staff Portal, Staff Resource>Dietitian Procedure Manual>UPDATES
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| Racing To Save Lives | HMC is proud to announce that Kim Bartolomeo, RD is in training to race for the benefit of others. Please Read more by clicking here. Visit her webpage to contact, encourage and/or support her. |
| Food For Thought |
When documenting remember to stick to the facts:
Be objective, not subjective. Please send your menu related questions to me via  email or call the office 916-364-5300.
Janet Montano, RD Director of Menu Services |
| Contact the Editor |  Please send your RDNews comments, suggestions & questions to Judy Morgan, MBA, RD |
| Staff Tips |
Thank you for sending me your pictures.
Please send Pati your comments, questions and tips in regards to HMC staff tools,email, website, etc. |
| Quick Links
HMC Staff Site
| | RDNews Archives
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Greetings!
This edition of RDNews provides a refresher on the appropriate procedures for medical record documentation. Click here for a pdf article of the information from this issue. |
Medical Record Documentation |
Medical records are legal documents. It should be assumed that any and all clinical documentation will be scrutinized at some point by regulatory agencies and/or legal representatives. Anything written on a medical record needs to be:
- accurate
- appropriate
- legible
- permanent
- dated
- signed or initialed
Documentation should have all the "C's":
- clear
- concise
- correct
- complete
- comprehensive
- collaborative
- centered on the resident and
- confidential information
Documentation and record keeping is a fundamental part of clinical practice. It demonstrates the clinician's accountability and records their professional practice.
Documentation is a record of the care and the clinical assessment, professional judgment, and critical thinking used by a health professional in the provision of that care.
Documentation is often used to evaluate professional practice as part of quality assurance mechanisms such as performance reviews, audits, accreditation processes, legislated inspections and critical incident reviews.
Clinical staff have legislative, professional and ethical obligations to protect resident confidentiality. This includes maintaining confidential documentation and resident records.
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RD Tip | | RD's medical record documentation should be able to demonstrate:
- a full account of the nutrition assessment of the resident and the care planned and provided
- relevant information on the resident's condition at any given time and the interventions and actions taken
- evidence that the RD met their duty of care and took all reasonable actions to provide the highest standard of care
- a record of all communications with other relevant disciplines in relation to the resident
Standards of Practice for medical record documentation include:
- Use only black permanent ink
- Make sure each page of the record being documented has resident name and identifier number
- Date, time and sign with your title (RD) on all medical record entries per CA Title 22
- Correct errors by lining through once, and initialing the entry
- Do not use White-Out or correcting tape on the medical record
- Use "addendum" and date to add to a completed medical record note on the same day
- Use "Late Entry for xxxxxx date" to document on a record when the event already occurred but the documentation was not done at the time (never back date documentation)
- Do not write over or change any previous documentation
- Correct any inaccurate data by making a new chart note with date and time and describing the nature of the correction
- Use only approved abbreviations in documentation
- Electronic health records will abide by the same general guidelines and HMC staff will follow facility policy and procedure for the electronic health record system
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| Dear Dietitian |
Notify Senior Staff for assistance if you feel you may be placed in an awkward situation by someone asking you to add documentation to the medical record or write something that does not follow our HMC standards of practice.
Please see the side bar for an important update which requires your signature.
Sincerely,
Judy Morgan, MBA, RD
HM Composite |
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Registered Dietitian Newsletter
