Proper charting is essential as it helps to provide continuity of care and legal documentation for the client's visits. Proper documentation of client care is imperative as improper charting can put the center at legal risk and cause confusion among volunteers and staff.
To maintain continuity of care, the complete client chart should include the following:
Limited medical history
Date and reason for the visit
Education she received
Services she received
Pertinent notations of the advocate/medical professional
Applicable forms, consents & releases
The signature of the person(s) providing services
Client files protect the center from legal liability when properly maintained and should be treated with the same importance as any other legal document. As a best practice, pregnancy medical centers, should be following HIPAA privacy practices to ensure that their centers are providing the highest quality of service in integrity. Client files should be kept in a secure location in a locked file cabinet or should be securely kept on an Electronic Medical Records software.
Follow these tips to ensure accuracy and professionalism when creating notations in a chart:
Only blue or black ink; no pencil
Full signature as opposed to initials
Only commonly used abbreviations
Draw one line through mistakes
No opinions or feelings of the advocate
Chart immediately after visit
A good rule when recording notations or observations is to follow the acrostic FACT:
Factual, Actual, Concise, Timely
Factual & Actual work hand in hand. There is not place in a chart for personal feelings or opinions. Only things that have transpired or were observed should be recorded.
Concise: Prioritize facts that actually matter. Don't record anything that won't be pertinent down the road to others reading the chart or helping the client.
Timely: Make notations soon after the client leaves for the most accurate notations. Leave time between appointments to complete this extremely important task.
Secure: Security matters. Make sure to keep client charts in a safe place that is inaccessible to those outside of your organization. Always follow HIPAA privacy policies.
Implementing regular evaluations and auditing of charts and processes will ensure your staff is equipped with the necessary tools to maintain proper charting practices.