• R L Asbell.
• University of Medicine and Dentristry of New Jersey-Robert Wood Johnson Medical School at Camden, USA.
• J Ophthalmic Nurs Technol. 1998 Nov 1; 17 (6): 231-5.

Abstract1. Use of forced entry charts facilitates proper chart documentation and helps assure compliance with Medicare's chart documentation requirements. 2. Nurses and technicians are responsible for up to two-thirds of the required chart documentation in the patient's record. 3. Performance and documentation are not synonymous. There must be a meticulous written record of what was performed as well as negative and positive findings for both the history and the examination portions of the exam. Recording possible, probable, and rule/out diagnoses enhances the level of complexity of medical decision-making.

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