Date
of Last Review 5/6/08
SME: Director of Health Information Management
The medical chart provides a complete, accurate, and timely record of the patient's
condition at given points throughout their stay.
The medical record must accurately reflect each clinician's input in the patient care process.
What to document:
Clinicians need to document their further attempts at capturing relevant patient data on the assessment tools when tools are noted to be incomplete due to various patient conditions
Example: Patient is aggressive, psychotic, unresponsive.
The clinician responsible must identify any added clinical information to the assessment tool or other forms in the medical record as follows:
Enter into Sunrise the word addendum and enter the information on the newly collected data. If Sunrise is down write on a paper copy of the form the newly collected data. Date,Time |
 | Indicate at the bottom of each assessment page, in which data was entered, that s/he has updated the page or form |
 | Date |
| Initials |
| Signature and licensure of the clinician adding/inserting information |
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