BOP Program Statement 6090.04 § 7

The health record will contain information needed to: support the inmate’s diagnosis and

condition; justify and document the course and result of care, treatment, and services; and provide

continuity of care among providers.

a. General Guidelines

■ All health record entries will be legible.

■ Paper record entries will be made in blue or black ink.

■ Military time (0700, 1200, 1400, etc.) will be used for all entries in the health record.

b. Abbreviations. Abbreviations are generally to be avoided. Standard abbreviations are

listed in Appendix C.

c. Authentication

■ Electronically generated health records will automatically record provider name and

credentials, ensure legibility, and assign the date and time to entries.

■ In paper records, health care providers will sign their name and credentials and use a block

stamp or printed name and credentials.

■ Only authorized individuals make entries in the record.

■ Staff members will document in the electronic health record when logged in under their own

account. At no time will staff allow others to document under or otherwise use their EHR

account.

■ Staff will personally document care, treatment, and services that they provide. When

dictation is approved in advance by the Chief of Health Information, documentation may be

transcribed for signature of the care provider. These requests will be made via annual

exception to policy memorandum to the Health Services Division.

d. Timeliness of Entries. To ensure integrity of the record, documentation of patient

encounters and treatments will be completed as soon after the event as possible. Documentation

is expected to be completed no later than the end of the shift. When this is not possible, the

documentation will be labeled as “LATE ENTRY” with a brief explanation of the delay following.

Documentation of on-call contacts will be co-signed or documented on the staff member’s next

business day. At no time will late entries exceed 30 days after the encounter. After 30 days, an

administrative note can be made to add information regarding an encounter.

e. Correction of Errors and Amendments

(1) Correction of Errors in Paper Records. A neat line will be drawn through the incorrect

information with an explanatory note (i.e. error, wrong chart). The date of the correction and the

person's initials will be added to the corrected documentation.

(2) Electronic Records. When available, the amendment process will be used to correct

mistakes in documentation in the electronic record (left versus right, missing documentation of a

body system, etc.). When amending a note, the provider will state the reason for the amendment.

P6090.04 3/2/2015 12

P6090.04 3/2/2015 13

Entry error should generally be reserved for instances where staff documented on the wrong

patient/in the wrong record.

f. Co-signatures and Review

(1) Co-signature. Co-signing documentation is the act of a licensed independent provider

validating and taking responsibility for the content and orders he/she gave to those authorized to

accept orders. When errors are found, the cosignatory should write a subsequent note simply

correcting the order or clarifying the information in a professional manner.

(2) Review. Signing as a reviewer of a document should be limited to instances where the

reviewer precepts a student or new employee; or provider review of scanned documentation (i.e.,

scanned consultation or laboratory report). It implies the reviewer’s responsibility for the content

of the document. It is not to be used to only to notify someone about the existence of the

documentation.