AAO-HNSF Certificate Program for Otolaryngology Personnel

All lab results need to be signed and dated by the physician.

Entries in the medical record should be made in a timely manner. This holds true especially if there is an adverse or unsatisfactory outcome. A malpractice claim may arise from this event. Never rely solely on your memory or memories of your witnesses. Your record may become the only means of keeping the facts straight. A good “rule of thumb:” the history and physical should be recorded within 24 hours of admission, surgical notes should be entered immediately following a procedure, and a full surgical report should be made within 24 hours. Telephone and/or verbal orders should be countersigned within 24 hours. Document all follow-up conversations on previously discussed problems, recommendations, and test results. A patient’s compliance or noncompliance, missed appointments, and follow-up telephone calls also must be documented. Patient education needs to be documented as well. The record must show that the patient was fully and carefully instructed on possible adverse reactions to new medications, potential long-term effects of the medications prescribed, limitations/restrictions following surgery, and exercise regimens. It is also important to document that the patient acknowledges that they understand this information. If family members of the patient are included and present during the review and discussion of educational materials, this needs to be documented as well. If a correction must be made in the medical record, strike a single line through the error and make the corrections, ensuring that they stay in chronological order, and initial and date the correction. Striking a single line through the error allows for the original entry to remain legible. Under no circumstances should you cross out completely or use correction fluid to remove an error. Never squeeze corrections between lines or in the margins of the medical record. If more space is needed, you can add an addendum to the record. Label it as “addendum,” add the current date that it is being written, and reference the original entry. If your office utilizes dictation services for the medical record, you must proofread them carefully prior to signing and dating them. Don’t assume that what you dictated is what is going to appear on the transcribed note. Corrections to Medical Records

If a correction must be made in the medical record, strike a single line through the error and make the corrections . . .

In addition, you should never make corrections after a complication that has occurred, copies of the original record have been released, or a lawsuit has been filed. Never destroy or remove any of the pages from the patient’s medical record.

Other Documentation

All patient contacts need to be documented. This includes scheduled appointments, office visits, hospital visits, missed appointments, no-show appointments, and telephone conversations. Telephone conversations that need to be documented include: patients calling with any clinically relevant information, calling for prescription refills, advice or instructions given, completions or concerns expressed by the physician or the patient, follow-up