Shade ink in the Professional Medical History

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Aug 6th, 2022
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How to shade ink in the Professional Medical History

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today Im going to show you how to approach history-taking going to learn the art of History taking and improve your consultation skills you have click on the right video if youre new to this channel hi my name is Dr. Erwin Kwun my mission is to help doctors lead a happy and fulfilling life I publish new video every Thursday on the subject of happiness and success if you have not already subscribed to this channel dont forget to subscribe and ring the bell so you are notified first each time I release a new video imagine yourself taking a history and the conversation flows smoothly between the patient and you effective communication is key in clinical practice the approach to consultation is vital in eliciting history how do you take a history traditional medical history model consists of presenting complaint history of presenting complaint past medical history family history social history drug and allergy history and system review all this medical information is relevant and could

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Maintenance and Legibility of Record Handwritten entries should be made with permanent black or blue ink, with medium point pens. This is to ensure the quality of electronic scanning, photocopying and faxing of the document. All entries in the medical record must be legible to individuals other than the author.
Financial paperwork (e.g., credit card applications) and some other types of legal documents (such as those requiring a signature) usually require using a blue ink pen. If you were to use any other kind of ink, especially black, it would be difficult to determine whether the documents are original or photocopied.
Ideally, all entries in the medical record should be made in black ink. This would make it simple to produce a photoreproduction and ensure that the subsequent copies would be legible.
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
There is no legal requirement to use any particular color of ink, a document signed in crayon or pencil has the exact same legal standing. Some institutions prefer blue ink because it stands out from black print and makes a BW photocopy obvious.
All Medical Records, regardless of form or format, must be maintained in their entirety, and no document or entry may be deleted from the record, except in ance with the destruction policy (refer to section IX). Handwritten entries should be made with permanent black or blue ink, with medium point pens.
There is no legal requirement to not use blue ink on medical records. However, some healthcare organizations may have policies in place that require or prefer black ink be used instead. This is because the color of the ink can affect the readability of photocopies and scans of medical records.

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