In general, the desirable characteristics of the medical record can be summarized by the acronym CHART (Beckman):
(1) Complete
(2) Honest
(3) Accurate
(4) Readable (and legible)
(5) Timely, with date and time recorded
It would be fairly easy to create a score based on a 5 point Likert scale for each characteristic.
In addition to doing things right, there are some BAD things to avoid.
(1) Blaming or badmouthing others
(2) Altering anything unless this is done according to established hospital practice, including proper dating, timing and initialing
(3) Deleting or removing any part of the record
Even if nothing wrong was done, the appearance of trying to hide something or lie can make life unpleasant in court. If something wrong was done intentionally, then this is considered tantamount to admission of guilt if it is ever discovered.
