As the health care industry’s most comprehensive library of customizable policy and procedure templates, MCN Healthcare’s Home Infusion Therapy Policy and Procedure Manual includes this customizable template, Legibility of Medical Record Documentation. MCN’s policy library helps you meet compliance with Joint Commission and federal regulations including CMS, CDC, OSHA, OIG, HIPAA and more.

MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors.

Here is some sample content from Legibility of Medical Record Documentation:

	POLICY: It is the policy of Agency to set legibility standards for medical record documentation and to monitor compliance with these standards as part of our performance improvement and medical error reduction activities. This policy is applicable to all documentation within the medical record. PROCEDURE: Whenever possible, all consults, histories and physicals, interpretations of diagnostic testing, and post operative/procedure results shall be dictated. Only abbreviations listed in the organization's list of approved abbreviations will be allowed for use in medical record...
Second excerpt:
	...dosage form. A leading zero must precede a decimal expression of less than one. A terminal zero is not to be used after a decimal. Prescribers are to avoid the use of abbreviations for drug names and Latin directions for use. The age and weight of the client especially geriatric and pediatric clients should be included where appropriate. If a healthcare professional writes an order that is not legible, the order must be clarified with the healthcare professional prior to...