Consistent style of entry is easy with autonotes.NYSDA RISK MANAGEMENT
This document is intended to be informational and should not be construed as definitive legal advice. Consult your own attorney for legal advice. (revised September 26, 2011)
Patient Record Entry Rules:
ALWAYS Rule:
• Use a consistent style of entry
• Use ink
• Write legibly
• Express concern
• Date and initial all entries
Use ink pertains to not altering your records, not an issue in OD, since every change is saved.
Write legibly is not an issue with a typed record.
Date & initial all entries is for proof that you personally wrote or reviewed the note personally.