Date of Last Review 11/12/09
Date
of Last Review 10/07/10
SME: Director of Health Information Management
Only authorized individuals may document in the medical chart. All chart entries
must be legible. See Patient
Medical Chart
This policy is applicable to all healthcare professional's documentation within the medical chart including nurse's notes, progress notes, treatment plans, and physician's orders. See Medical Record Documentation
If physicians or other authorized healthcare professionals:
 | Make an entry in the medical record that is not legible, they receive a letter from the Chairperson of the Medical Records committee |
| Receive two letters from the Medical Records Chairperson, their names are forwarded to their respective supervisors for further action |
Legibility is monitored through retrospective Chart Review. If two chart reviewers cannot read the entries made in the chart, then it is determined illegible.
Legibility problems are reported as follows:
| Issues with physicians are reported to the Medical Executive Committee and Medical Staff Committee |
| Issues with other healthcare professionals are reported to the department managers and made a part of the annual review process |
| Quarterly to the Medical Records Committee |
| To the Performance Improvement Committee, and other applicable committees as needed |
The Joint Commission : Management of Information
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
