What Basic Information Should I Be Sure to Include in the Medical Record?

Before we address the basics of documentation, I would like to talk about the need for all your documentation to be legible to anyone who may read it. If you know you have poor penmanship, begin to print. Your printing will make life much easier for the person who is reading or transcribing from your notes. Now that you're printing, let's talk about the basics.

It may seem obvious but be sure to include the date and the time you wrote your entry. The date should include the year; the time should indicate am or pm. Don't chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.

Other essential information to record is: the client's history (including unhealthy conditions or risky heath habits such as scalp lice, smoking, failure to take prescribed medication, etc.) A client's history is usually reflective of trends and may offer valuable hints about what to expect in the future. It is important that you chart any subjective (what you hear) and objective (what you see) observations (especially changes in health status such as the emergence of a productive cough, difficulty in breathing or feelings of anxiety or depression). Document any actions that you did in response to any of your observations and the client's response to your actions. These responses to your interventions are commonly called client outcomes.

Client outcomes (including those that are deviations from what you expected) should be charted in the record. For example: if a client is in pain, observe and document how that pain is experienced both objectively (what you see) and subjectively (what you hear). Record where the pain is and the level of intensity or severity (perhaps you will use a pain scale to do that). Record the medication and the backrub you give to relieve the pain and whether or not those actions were effective, i.e., did the pain persist, recur, or go away?

It is a good idea to document the client, family member or significant other's actual response (verbal or non-verbal) to any aspect of care provided even if you were not the one providing it. Doing so indicates that you have evaluated the results of care. It is perfectly acceptable to chart the client's verbal responses in the record as long as you use quotation (") marks. Non-verbal responses should be described in as much detail as possible.

Be sure to record your full name, credentials and job title in the required section on documentation forms. Some forms will ask you to record your initials as well. Your signature must be in cursive writing so a word of final caution: do take the time to sign your name legibly.

Documenting the Basics
  • Chronology: Date and Time
  • Client History
  • Interventions: Medical, Social and Legal
  • Observations: Objective and Subjective
  • Client Outcomes
  • Client and Family Response
  • Authorship: Your Full Name, Title, Credentials and Signature