19Clinical
Clinical documentation & charting
If it isn't charted, it didn't happen. Documentation is how we keep patients safe, get paid, and protect the company in audits.
Timeliness
- Encounter notes closed within 24 hours of the visit
- Orders entered before the patient leaves the room
- Phone encounters charted same day
- No backdating — use a late-entry addendum with today's date
What belongs in the chart
- Subjective, objective, assessment, plan
- Patient's own words in quotes for key complaints
- Clinical reasoning, not just conclusions
- Coordination with other providers (who, when, what was shared)
- Patient education provided and the patient's response
Corrections & addendums
0/4What never goes in the chart
0/4Copy-forward is not documentation
Cloning a prior note without reviewing and updating each section is a billing-fraud risk. Pull forward structure if you must, but every assessment and plan must reflect today's encounter.