If pre-dating or back-dating occurs it is critical that the underlying reason be identified to determine whether there are system failures. The cause must be evaluated and appropriate corrective action implemented. Entries should be made as soon as possible after an event or observation is made. Anyone documenting in the medical record should be credentialed and/or have the authority and right to document as defined by facility policy.
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You do not need to obtain permission to cite, reference, or briefly quote this material as long as proper citation of the source of the information is made. Please include the title and URL of the content you wish to reprint in your request. Fax Copies When fax records are maintained in the medical record the assurance must be made that the record will maintain its integrity over time. For hard copy/paper records facilities should document in blue or black ink only.
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At times carbon copies of documents (i.e. TO’s ) may be used on a temporary basis and the original will replace the carbon – this is considered an acceptable practice. Printers When documentation is printed from a computer for entry in the medical record, the print must be permanent. For example, a laser printer would be used rather than an ink jet printer because the ink is water-soluble. The federal regulations for long term care facilities do not require countersignatures for nurse practitioners and physician assistants. It is important to know state licensure and professional practice regulations for a NP/PA to determine if countersignatures are required.
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