The Six C's of charting

Clarity

Use precise descriptions and accepted medical terminology when describing a patient's condition

Chronological order

All entries must be dated to show the order in which they are made. Very important for patient care and in case of legal questions.

Conciseness

Brief and to the point. Abbrev. And specific med terminology can often save time and space. Every member of your staff should use the same abbrev.

Completeness

Fill out completely all the forms used in the patient record. Provide complete information that is understandable to others when making any notation in the chart

Confidentiality

Only the patient, attending physicians, and the medical assistant are allowed to see the charts without the patient's written consent

Client's (patient) words

Record the patient's exact words rather than your interpretation of them. Often provides clues for the diagnosis.