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U.S. Department of Health and Human Services
Risk Management

Risk Management DOs and DON'Ts

Section Fourteen

DO

  • Do maintain proper licensure, credentials, and privileges at all times.
  • Do maintain professional decorum at all times.
  • Do treat patients with dignity and respect.
  • Do write legibly.
  • Do use only standard terminology and avoid abbreviations when charting. Chart professionally. Use proper grammar, punctuation, and spelling.
  • Do chart as soon after the event as possible. Entries must be “reasonably contemporaneous” with the care that was given.
  • Do chart comprehensively. Chart as much as is reasonably possible. Ideally you would chart in detail everything that was done. This would include charting results that are essentially normal or unremarkable; “if it’s not charted, it didn’t happen.”
  • Do be objective and descriptive in your progress notes; avoid being subjective or conclusory. For example, do not say, “The patient is a long-time drunk.” A better entry would read, “The patient reports a history of alcohol consumption of approximately [amount] for the past x years.”
  • Do note in the chart any non-compliance with the prescribed treatment regimen. This could include, for example, failure to keep appointments, failure to adhere to treatment regimens, failure to take prescribed medications, etc. Make sure these entries are polite and objective. Do not use the record to insult, chastise, or denigrate the patient.
  • Do initial and date all laboratory slips as they are reviewed. This shows that the laboratory results were reviewed and considered.
  • Do initial and date all ECG rhythm strips, fetal monitor strips etc. while they are running. Whenever medications are given or other actions are taken that could affect the heart rate or other physiological measures under observation, this should be noted by making an entry on the strip.
  • Do obtain proper written, informed consent prior to any non-emergency invasive procedure.
  • Do establish and maintain an accurate system of warning labels on charts of all patients with known drug sensitivities.
  • Do respect Tribal customs.

DO NOT

  • Do not reprimand, criticize, or complain about other members of the health care team within sight or hearing of patients.
  • Do not criticize other staff members in the medical record.
  • Do not write in the record that malpractice occurred or that anyone is legally liable.
  • Do not engage in debate within the medical record.
  • Do not become emotional in chart entries. The chart is not the place for catharsis. Nor is it the proper place for editorials or opinion pieces.
  • Do not obliterate or alter errors in the chart. Correct them by drawing a single line through the error, writing “error” above the lined out wording, recording the correct information and signing and dating the correction.
  • Do not discard or destroy any part of the medical record or any other hard copy diagnostic printouts such as monitor strips, blood gas readings, etc.
  • Do not promise a “cure” or improvement and do not guarantee specific results. Avoid saying or doing anything that would unreasonably raise patient expectations.
  • Do not talk directly to a claimant’s or plaintiff’s attorney. Refer all such calls to the Government’s legal counsel, or simply say you cannot provide any information to them.

Section 15: Selected Resources