The three main purposes of documentation are to provide quality patient care, secure appropriate reimbursement, and avoid malpractice actions. The National Committee for Quality Assurance (NCQA) has set the basics of proper documentation. Here are the minimum requirements:
Patient identification, personal/biographical data, provider identification, entry date, legibility, problem list, allergies, past medical history, smoking/alcohol/ substance abuse, physical exam, history and physical, working diagnosis, plan/treatment, patient education/instructions, consults/X-ray/imaging reports/referral records, follow up/return visits clearly documented, and clear case management.
Signs of poor documentation include pencil/white-out/erasures, illegible documents, non-standard abbreviations, dates and signatures absent, blank spaces, lack of identifying information on each page, undocumented consents, using something other than blue or black ink, use of correction fluid.
Corrections are allowed. Simply put one line through it, make your correction and initial and date the change. The easier your charts are to read the better they will hold up under scrutiny.