Health Record Management and Documentation
What the record must show
The health record is a legal document and the facility's evidence that care was delivered. Entries should be objective, dated, timed, signed with credentials, and written at the time of care or as soon as possible after it. Use the facility's adopted format - problem-oriented notes, SOAP (subjective, objective, assessment, plan), or DAR (data, action, response) - and use it consistently.
Do and don't
Do quote the patient: 'states, "it feels like someone is standing on my chest."' Do record vital signs, interventions, response, education given, and provider notification with the time and the response. Do label late entries as late entries.
Don't alter, back-date, or obliterate an earlier note; correct with a single line, initial, date, and time. Don't chart opinions about guilt, veracity, or discipline ("malingerer," "should be written up"). Don't file incident or security reports in the medical record - they are separate documents - and don't chart speculation.
Confidentiality and access
Medical information is shared on a need-to-know basis. Custody staff usually need housing, work, and safety restrictions, not diagnoses. Release to outside parties requires valid authorization, a court order, or a subpoena handled per policy. A common trap: "privacy law means we cannot tell the officer anything." False - the HIPAA Privacy Rule permits disclosures to correctional institutions for treatment, health and safety, and certain administrative purposes.
Refusals and continuity
Document informed refusal in the patient's own words, what was offered, risks explained, and provider notification. Send a transfer summary with the patient; incomplete handoffs cause missed doses and missed appointments.
Worked example
A nurse realizes at end of shift she forgot to record a dose. Correct action: write an accurate late entry describing what was given and when, and notify the supervisor per policy - never back-time the entry.