3.4.3 Writing Medical Documentation

In your daily practice, all tasks are to be documented after they are completed. When you are entering information in the legal medical record, it must be completed in pen if the record is on paper. If you make an error, do not white it out, but instead strike it out with one clear line and write the correction legibly. Initial and date the correction so that it is clear when the correction was noted.


These days of shelves full of medical records are, thankfully, coming to an end as more efficient digital records take over.

Did You Know?

You may occasionally come across SOAP notes in medical documentation. SOAP notes are provided by some health care staff after visiting a client. Check out this example of SOAP notes in practice, and a list of common abbreviations used in medical documentation.

Review “Clinical documentation and how to document medical information well” by Sarah Syed for some general guidelines regarding medical documentation. Please note that this article is written for nurses, who will likely be providing more advanced medical notes than you. However, the general guidelines are still useful to apply in your own practice, and understanding how medical documentation is written will help you understand it quickly and locate the information you are looking for.

Whenever you add comments to a medical document, there are common writing pitfalls that can lead to miscommunication and human error. Review this article that shows some problematic statements and how they should be corrected.

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