What are the best practices for documenting patient information in a medical chart?

Professional Documentation in Patient Charts

Document patient care using a structured, time-based format that includes all essential clinical elements while maintaining clarity, brevity, and clinical relevance—prioritizing the patient's narrative alongside objective findings, assessments, and management plans. 1

Core Documentation Components

Patient Demographics and Identification

• Record patient name, address, telephone number, age, and weight at every encounter 2
• Include the name of the patient's personal care provider or medical home 2
• Document hospital unique identification number and date of birth for proper patient identification 3

Vital Signs and Physical Status

• Document heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 2
• If vital signs cannot be obtained due to patient non-cooperation, explicitly document this occurrence 1, 2
• Include physical status evaluation (ASA classification when applicable) 1

Comprehensive Health History

• Allergies and adverse reactions: Document all allergies and previous allergic or adverse drug reactions 1, 2
• Medication history: Include prescription medications, over-the-counter medications, herbal supplements, and illicit drugs with dosage, time, route, and site of administration 1, 2
• Relevant diseases and physical abnormalities: Document conditions that may affect treatment, including genetic syndromes, neurologic impairments, obesity, history of snoring or obstructive sleep apnea 1, 2
• Pregnancy status: Document for all females of childbearing age 1, 2
• Previous hospitalizations: Summarize relevant prior admissions 1, 2
• Seizure disorders: Document any history of seizures 1, 2
• Anesthesia/sedation history: Include any complications or unexpected responses 1
• Family history: Particularly related to anesthesia complications (malignant hyperthermia, pseudocholinesterase deficiency, muscular dystrophy) 1

Review of Systems

• Focus specifically on abnormalities of cardiac, pulmonary, renal, or hepatic function that might alter expected responses to medications 1, 2
• Query and document signs and symptoms of sleep-disordered breathing or obstructive sleep apnea 1, 2
• Document symptoms related to the presenting condition 2

Physical Examination

• Perform focused evaluation of body systems relevant to the patient's condition 2
• Include airway assessment: tonsillar hypertrophy, abnormal anatomy (mandibular hypoplasia), or other factors increasing risk of airway obstruction 1, 2

Documentation Structure and Format

The Patient's Narrative

The clinical record should include the patient's story in sufficient detail to accurately retell the story. 1 This represents the foundation of professional documentation and should drive the remainder of the examination and decision-making process 3.

Use of Templates and Macros

• Macros and templates may improve completeness and efficiency when used appropriately, particularly for standardized terminology like review of systems and physical examination findings 1
• Critical caveat: Avoid copying entire notes without editing, as this propagates factual errors, outdated information, and contradictory data 3
• When data are pulled from another location in the chart, indicate the source and supplement with appropriately abstracted narrative content 1

Copy-Forward Functionality

• When previously documented clinical information remains accurate and adds value, "review/edit/attest and copy/forward" may improve accuracy, completeness, and efficiency 1
• Warning: This technique can be misused to the detriment of accuracy, high-quality care, and patient safety 1
• Always thoughtfully review prior relevant information and provide rich historical context rather than blindly copying 1

Time-Based Documentation During Procedures

For procedural documentation, maintain a time-based record including:

• Name, route, site, time, dosage per kilogram, and patient effect of all administered drugs 1
• Dosage calculation pitfall: For obese patients, most drug doses should be adjusted to ideal body weight rather than actual weight 1
• "Time out" confirmation documenting patient name, procedure to be performed, and laterality/site of procedure 1
• Inspired concentrations of oxygen and inhalation agents with duration of administration 1
• Continuous monitoring data: level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, expired carbon dioxide values, and oxygen saturation 1
• All adverse events and their treatment 1

Assessment and Management Plan

• Document positive findings noted during evaluation 2
• Formulate and clearly document the management plan 2
• For hospitalized patients, write a note documenting that the chart was reviewed, even if using the current hospital record 1
• If the clinical or emergency condition precludes acquiring complete information before treatment, document this and obtain the health evaluation as soon as feasible 1

Documentation Standards and Professional Etiquette

Key Principles

• Clarity and brevity: Documentation should emphasize clarity, brevity, and attention to the needs of other readers, including patients 1
• Nonjudgmental approach: Write from the perspective of a neutral reporter without making unnecessary judgments or drawing conclusions 4
• Patient-focused: Keep documentation relevant and comprehensive, including psychosocial and emotional concerns alongside physical observations 4
• Standardized format: Each organization should develop "chart etiquette" principles based on well-defined professional standards 1

Common Pitfalls to Avoid

• Failing to document non-cooperation: Always note when vital signs cannot be obtained due to patient behavior 2
• Omitting medication interactions: Document complete medication history that could interact with treatments 2
• Inadequate allergy documentation: Never skip documenting allergies and previous adverse reactions 2
• Missing baseline status: Document baseline health status for comparison during treatment 2
• Excessive copy-paste: Avoid propagating outdated or incorrect information through indiscriminate copying 3

Discharge and Recovery Documentation

• Document time and condition at discharge from treatment area or facility 1
• Confirm that level of consciousness and oxygen saturation in room air have returned to a safe state for discharge by recognized criteria 1
• For patients receiving supplemental oxygen before the procedure, document similar oxygen need after the procedure 1
• Document instructions given to the responsible person regarding post-procedure care 1
• Note that some medications have long half-lives and may pose risk of re-sedation, potentially requiring longer observation periods 1

Legal and Regulatory Considerations

• Documentation provides necessary information for discovery and review of conduct in liability issues 5
• Written documentation is key to successful open-communication partnerships among providers 5
• Accurate, appropriate, and concise documentation is essential for patient safety, continuity of care, reimbursement, and quality of care challenges 5
• Documentation should demonstrate how interventions improved patient care, not just serve reimbursement purposes 5