Back in 2004 the Board posted guidelines on charting. These can be found at the link below.
Whether entering all patient information (visits, prescriptions, telephone or other communications) on a computer or handwriting all entries, the ability to use this information must be considered.
There are three main reasons for charting:
1. Document all interactions ... With good documentation, you, as the doctor, can go back and respond appropriately to the patient's needs;
2. Continuity of Care ... Continuing the patient's care by you, in conjunction with other health care providers, or in the future care provided by a different doctor or other health care provider, will go more smoothly with good legible charting; and lastly
3. Insurance ... The notes in a patient's chart should substantiate the care provided. True, NDs are not responsible to insurance companies; however, a doctor is responsible to the patient and often the patient needs to work with an insurance company to pay for the care they have recieved and want to continue to receive.
Therefore good record- keeping is important.
Charting Guidelines
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