Documenting in the Electronic Health Record
Write documentation that is accurate, objective, and defensible, and understand what the record is actually for.
By the end of this lesson you can
- Distinguish objective from subjective documentation
- Document within your scope, without interpreting
- Correct an error in the record properly
- Explain why the record is a legal document
Lesson Notes
Read through the key concepts before you try the challenge.
The record outlives the visit
You document a visit at Lakeside Medical Associates.
You write 'patient seems anxious and is probably overreacting to mild symptoms.' Two years later that sentence is read aloud in a deposition. It contains a judgment you were not qualified to make, about a patient whose symptoms turned out to be significant.
Your task: Document what you observed and what the patient said, and nothing else.
The medical record serves clinical care first, but it is also a legal document, the basis for billing, and the evidence in any dispute. Everything you enter carries your name and a timestamp, and it is permanent.
| Write this | Not this | Because |
|---|---|---|
| "Patient reports pain 8/10 in right lower abdomen" | "Patient in severe pain" | Severity is the patient's report, quantified — not your assessment |
| "BP 158/96, right arm, seated, large cuff" | "BP high" | High is an interpretation; the number and conditions are the fact |
| "Patient states 'I stopped taking it two weeks ago'" | "Patient is non-compliant" | Non-compliant is a judgment, and it prejudices everyone who reads it afterwards |
| "Patient declined the injection" | "Patient refused and was difficult" | Declining is a fact; difficult is an opinion with no clinical value |
| "Wound 3 cm, edges approximated, no drainage" | "Wound looks fine" | Measured description is reproducible; fine is not |
Errors are corrected, never erased. In a paper record, draw a single line through the error so it remains readable, write the correction, and initial and date it. In an EHR, use the amendment function — which preserves the original entry and records who changed what and when. Deleting or overwriting an entry destroys the audit trail and looks, in litigation, exactly like concealment.
You realize you entered a vital sign in the wrong patient's chart an hour ago. What should you do?
Challenge
Apply what you've learned in this lesson.
Documentation quality is a habit built one entry at a time.
- Rewrite each objectively: 'Patient was rude and uncooperative.' 'Vitals look okay.' 'Patient seems to be getting worse.' 'Wound is healing nicely.'
- Research the SOAP note format. Identify which sections an MA would typically contribute to and which belong to the provider.
- Write a complete intake entry for a patient presenting with a cough, using only objective language and quoting the chief complaint.
- Find out how your EHR — or any EHR you can research — handles amendments. Describe what the audit trail preserves.
Finished this lesson?
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