Clinical Documentation Standards and Requirements
Fundamental Principles of Clinical Documentation
Documentation Must Be:
- Accurate - Reflects the true clinical picture
- Complete - Contains all relevant information
- Timely - Documented at or near the time care is provided
- Legible - Readable by others
- Authenticated - Signed/co-signed by responsible provider
- Objective - Based on observations, not assumptions
Legal Requirements
- The medical record is a legal document
- Document only what you personally observed, did, or were told
- Use quotes for patient statements
- Never alter, backdate, or falsify documentation
- Late entries must be clearly labeled
Admission Documentation Requirements
History and Physical (H and P) - Physician
Timeframe: Must be completed within 24 hours of admission
Required Components
| Section | Required Elements |
|---|---|
| Chief Complaint | Reason for admission in patient own words |
| History of Present Illness | OLDCARTS: Onset, location, duration, character, aggravating/relieving factors, timing, severity |
| Past Medical History | Chronic conditions, prior hospitalizations, surgeries |
| Medications | Current medications with doses, frequency, route |
| Allergies | Drug allergies with specific reaction |
| Family History | Relevant conditions in first-degree relatives |
| Social History | Tobacco, alcohol, drug use; occupation; living situation |
| Review of Systems | Systematic review of all organ systems |
| Physical Examination | Comprehensive or focused exam; must include vital signs |
| Assessment | Working diagnosis/diagnoses |
| Plan | Diagnostic workup, therapeutic interventions, consultations |
Nursing Admission Assessment
Timeframe: Must be completed within 8 hours of admission
Required Components
- Patient identification verification
- Chief complaint and history
- Allergies with reactions
- Current medications (reconciliation completed)
- Pain assessment
- Vital signs with height and weight
- Head-to-toe physical assessment
- Fall risk assessment (Morse Fall Scale)
- Skin assessment (Braden Scale)
- Nutritional screening
- Advance directives status
Daily Documentation Requirements
Progress Notes - Physician (SOAP Format)
Timeframe: At least daily for all inpatients
| Section | Content | Example |
|---|---|---|
| S - Subjective | Patient symptoms, complaints | Patient reports chest pain resolved |
| O - Objective | Vital signs, exam findings, labs | VS: T 98.4, HR 78, BP 128/76. Lungs CTA. |
| A - Assessment | Updated diagnoses, interpretation | NSTEMI - improving on medical management |
| P - Plan | Treatment changes, disposition | Continue heparin. Schedule cath for tomorrow. |
Nursing Documentation Frequency
- Vital signs: Per order (typically q4h)
- Head-to-toe assessment: Every shift
- Pain reassessment: Within 1 hour of intervention
- Medication administration: At time of administration
- I and O: Every shift summary
Specialty Documentation
Operative/Procedure Report Requirements
Timeframe: Immediately following procedure
| Element | Description |
|---|---|
| Date and time | When procedure started and ended |
| Pre-operative diagnosis | Indication for surgery |
| Post-operative diagnosis | Findings from surgery |
| Procedure performed | Exact name with laterality |
| Surgeon and assistants | Names and roles |
| Anesthesia type | General, regional, local, MAC |
| Findings | Detailed description |
| Specimens | Description and disposition |
| Estimated blood loss | In milliliters |
| Complications | Any intraoperative complications or none |
| Condition at end | Patient condition upon leaving OR |
ICU Documentation Requirements
| Assessment | Frequency |
|---|---|
| Vital signs | Every 1-2 hours |
| Neurological assessment | Every 2-4 hours |
| Cardiac rhythm | Continuous; document changes |
| Respiratory (ventilator) | Every 2-4 hours |
| Intake and output | Hourly totals |
| Sedation/pain scores | Every 2-4 hours |
Discharge Documentation
Discharge Summary Requirements
Timeframe: Within 30 days of discharge (24-48 hours preferred)
| Element | Description |
|---|---|
| Reason for hospitalization | Principal diagnosis |
| Significant findings | Key diagnostic results |
| Procedures performed | List with dates |
| Hospital course | Chronological summary |
| Condition at discharge | Stable, improved, etc. |
| Discharge diagnoses | All diagnoses addressed |
| Discharge medications | Complete list with doses |
| Follow-up appointments | Specific providers, timeframes |
| Pending results | Outstanding tests with follow-up plan |
Discharge Instructions (Patient Copy)
- Diagnosis in lay terms
- Medications (new, changed, discontinued)
- Activity restrictions
- Dietary modifications
- Wound/device care instructions
- Follow-up appointments
- Warning signs requiring immediate attention
- Emergency contact numbers
Special Documentation
Informed Consent Required Elements
- Name of procedure
- Risks and benefits explained
- Alternatives discussed
- Questions answered
- Patient/surrogate signature
- Witness signature
- Provider signature
- Date and time
Restraint Documentation
Non-violent restraints:
- Clinical justification documented
- Order renewed every 24 hours
- Assessment every 2 hours documented
Behavioral restraints:
- Order renewal: Adults q4h, Children/Adolescents q2h
- Face-to-face evaluation within 1 hour
- Continuous monitoring
EHR Requirements
Authentication and Access
- Unique login credentials required
- Log off when leaving workstation
- Electronic signature is legally binding
- All entries automatically timestamped
Copy/Paste Guidelines
- Copy/paste is discouraged
- If used, must be verified and updated
- Author responsible for accuracy
- Avoid note bloat