1. F 514: COMPLETE, ACCURATE, ACCESSIBLE RESIDENT RECORDS
Accurate Documentation

2. OBJECTIVES:
Upon completion of this learning module, the
learner will be able to:
Discuss the components of a complete and accurate physician’s order
Discuss guidelines for completing medical forms
Discuss the importance of accurately documented physician’s orders and forms

3. Components of an Accurate Physician’s Order
Includes the drug or treatment and correlating diagnosis
Includes the route, dosage, frequency, and reason for administration (for medications)
Includes type of fluid or formula, amount, flow rate, mode of administration (pump/bolus/gravity) for parenteral/enteral nutrition therapy
American Health Information Management Association (AHIMA), nd

4. Components of an Accurate Physician’s Order
Includes stop orders for medications such as antibiotics or other treatment regimens
Telephone orders should be signed by the physician within the required time frame (5 days)
AHIMA, nd

5. Components of an Accurate Physician’s Order
Order is “Read back” by licensed staff as he/she has heard and interpreted the message and physician will confirm correctness
Order specifies whether it was a verbal or a telephone order
AHIMA, nd

6. Components of an Accurate Physician’s Order
Includes name of the prescribing physician, date, and time the order was obtained
Order is noted, signed, and dated by person receiving the order
AHIMA, nd

7. Completeness and Accuracy of Records
When documenting and completing forms (such as
the Transfer Acknowledgement Request/Consent/
Refusal, Fig. 1) remember to:
Document all facts and information
Do not leave any blank field
Use N/A to indicate a field was reviewed

8. Completeness and Accuracy of Records
When documenting and completing form(such as the
Transfer Acknowledgement Request/ Consent/
Refusal, Fig. 1) remember to:
Fill up the correct fields
Review the completed form (before filing or forwarding to intended recipient)

9. Importance of Accurately Documented Physician’s Orders and Other Medical Forms
Promotes resident safety
Prevents medication/ treatment errors
Reflects information about care and services the resident received
Prevents record tampering

10. Importance of Accurately Documented Physician’s Orders and Other Medical Forms
Meets acceptable professional standards and regulatory guidelines
Accurately reflects the actual wishes and/or choices a resident or responsible party
Prevents confusion between care providers and between care providers and residents

11. Fig. 1
“Patient refusal” field inadvertently initialed instead of “Patient request for transfer”
C.A

12. Reference
American Health Information Management Association (n.d.) Legal documentation standards. LTC Health Information Practice and Documentation Guidelines. Retrieved from