When recording information into a medical record, what should you do?

Using ink and including the date and time when recording information into a medical record is essential for several reasons. First, ink provides a permanent record that cannot be easily altered or erased, which is crucial in maintaining the accuracy and integrity of medical documents. This permanence is vital for legal documentation and patient safety, ensuring that all information recorded can be relied upon in the future.

Including the date and time is equally important, as it provides context for the entries made in the medical record. This information helps healthcare providers track the progression of a patient’s condition over time, understand the timeline of treatments or interventions, and maintain a clear history for any future care needed. It also supports continuity of care when multiple providers are involved, allowing them to make informed decisions based on the most recent data.

In contrast, using a pencil would compromise the integrity of the record, as pencil marks can be easily erased or altered. Relying solely on digital input might not be applicable in all healthcare settings, and it may not conform to policies that require handwritten documentation in certain circumstances. Writing in any format without standardization can lead to confusion and misinterpretation, which could adversely affect patient care. Thus, ensuring the use of ink, along with correct dating and timing, aligns with