The importance of accurate documentation to the quality of medical care given to patients is unquestioned. It is such an accepted element of patient risk reduction in hospitals and in court rooms that the corresponding maxim is: “If it’s not written down, it didn’t happen.” NYU Medical Center website reminds its employees that in addition to its importance in providing a chronological description of patient care, and communication to other health professionals, “proper documentation also facilitates:
- If an adverse event occurs, you will have a record of what transpired prior to and of the incident.
- Appropriate compliance and quality review evaluations.
- Collection of data that may be used for research and education.”
These concerns also apply to research with human subjects, whether it is conducted in a hospital setting where the chart is a legal document or elsewhere. It is common sense that accurately recording information is essential for providing accurate research data.
Basic Principles of Documentation
- Entries need to be legible. If your handwriting is not readable, PRINT.
- Date and sign or initial each entry you make at the end of the entry/page.
- Document immediately after you complete a procedure; details never so clear later on.
- Write complete entries; use standardized abbreviations only.
- Don’t document something for someone else.
- Don’t sign a document for someone else.
- Maintain the confidentiality of the record you are creating. Re-file subject files; don’t leave them open in common rooms where casual observers like other graduate students may view them. Don’t discuss subject information outside the research team.
Mistakes happen; if you make a mistake, correct it right away.
- Draw a single line through the incorrect entry:
120/80error 120/60 CAM / *5/21/07 (*if a different date.) So that you can still read it.
- Write “error” immediately after it and initial it.
- *Preferably, you realized your mistake right away and are correcting it the same day. If not, you should also include the date you are making the correction.
- Scribble over the entire original entry so that it is impossible to read.
- The implication may be made that you wanted to hide something.
- Do not alter or go back and correct entries. The more corrections in a record the less reliable a record appears to be; the more time that goes by the less reliable a correction appears to be.