I agree with Jason. Worry more about sounding educated rather than professional. Example, when a patient says they have a “crick” in their neck, it would be wise to know your nouns before charting, or else, you might chart something like “patient states she has a crook in her neck”. What?!?!!
Since no one seems to want to digest the information in my original answer, I’ll just narrow down what I look for when reviewing medical records:
– The nursing documentation supports services/medications given. If the patient receives dilaudid q 2h IV, there should be a pain assessment before and after administration, and some subjective verbage helps. “Patient states her neck feels better. Rates pain as 2/10”.
– If the patient refuses a treatment, always document it, no matter how small it may seem to you. If a facility is being audited due to complaints/allegations of poor quality of care, the last thing you want is to ignore charting ADLs, including if the patient refuses a bath/meal etc.
-If the patient has a sign/symptom that you feel needs to be reported (fever, pain, etc.) chart it, and include to whom and at what time you did so.
– If an aide or assistant is responsible for a pertinent part of the patient’s care (example, patient with a stage IV decubitus that requires repositioning), don’t rely on the aide/assistant to chart that it was done. You chart it, too, even if it’s once per shift.
-Never rely on the physician to chart anything. I’ve seen a physician chart a discharge note on a patient who expired the night before, and was pronounced by a completely different physician, at a completely different facility. Medicare doesn’t pay for the physician’s last word.
My background is acute care, so I can’t be helpful with rehab charting, but I have reviewed enough documentation to tell you that check boxes and flowsheets aren’t enough.