What Are Some Good Documentation Practices?

What Are Some Good Documentation Practices?

Documents should be signed and dated, reviewed periodically and filed in a systematic manner. Specific industry retention periods must be adhered to, including archive periods. Develop internal policies and procedures to outline how long each document type is held for, the storage location and the department responsible for those document’s upkeep.

Eliminate any inconsistencies across documents by standardizing templates and filing procedures. Any documentation preserved must be verifiable and follow an audit trail. This includes additions, updates, revisions and deletions to existing documents. Demagnetize computer drives containing sensitive information to ensure the information is destroyed.

Documents must be legible and well-kept. Keep originals whenever possible, and ensure dates are included on those original documents. Line through, initial and date any corrections to original documents. Attach reasoning supporting the corrections to any original documentation. All documentation should track progression through the file’s life; retain previous versions of the document as well as records of the last individual to access previous versions.

Keep sensitive documentation, such as private information, in a safe area away from public access. Medical records are subject to HIPAA and HITECH rules. Shred these types of documents when they no longer require storage.

Back up electronic documents and make sure document management systems remain validated. Place file paths at the bottom of each document to trace back to the original folder. Take caution when duplicating electronic documents, as files copied and pasted run the risk of containing incorrect information.