Practice Consideration
The purpose of a medical record is to be a chronological document that:
• Records pertinent facts about an individual’s health and wellness;
• Enables the treating care provider to plan and evaluate interventions;
• Enhances communication between professionals, continuity of care;
• Assists both patient/physician in communication with third party
• Allows the physician to develop an ongoing QA program;
• Provides a legal document to verify the delivery of care; and
• Is available as a source of clinical data for research and education.
The three principles of documentation are: (1)
•First, the documentation should record the risk-benefit analysis of important healthcare decisions in the clinical care of the patient
•The second essential point of documentation is to document the clinical judgment at critical decision points in healthcare.
•The last sovereign principle of documentation is that it should document the patient's capacity to participate in his or her own healthcare. (2)
When documenting, providers should consider the following reader audiences and ensure that the documentation should be clear, concise and understandable by:
•other members of the treatment team: on-call physicians, emergency physicians, and those colleagues covering one's practice when the clinician is on vacation or off shift
• utilization reviewers, members of professional standards review organization (PSRO) committees, insurers, quality assurance reviewers and similar review organizations, and procedures
• plaintiff's attorney
•patients themselves
What guides documentation requirements?
•Statutory and regulatory requirements(3)
•Accreditation and certification requirements(4)
•Institutional policies/procedures
The National Committee for Quality Assurance (NCQA) identifies the following " Commonly Accepted Standards for Medical Record Documentation":(4)
1. Each page in the record contains the patient’s name or ID number.
2. Personal biographical data include the address, employer, home and work telephone numbers and marital status.
3. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials.
4. All entries are dated.
5. The record is legible to someone other than the writer.
*6. Significant illnesses and medical conditions are indicated on the problem list.
*7. Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
*8. Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
9. For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances (for patients seen three or more times, query substance abuse history).
10. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints.
11. Laboratory and other studies are ordered, as appropriate. *
12. Working diagnoses are consistent with findings.
*13. Treatment plans are consistent with diagnoses.
14. Encounter forms or notes have a notation, regarding follow-up care, calls or visits, when indicated. The specific time of return is noted in weeks, months or as needed.
15. Unresolved problems from previous office visits are addressed in subsequent visits. Guidelines for Medical Record Documentation (5)
16. There is review for under - or overutilization of consultants.
17. If a consultation is requested, there a note from the consultant in the record.
18. Consultation, laboratory and imaging reports filed in the chart are initialed by the practitioner who ordered them, to signify review. (Review and signature by professionals other than the ordering practitioner do not meet this requirement.) If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of followup plans.
*19. There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.
20. An immunization record (for children) is up to date or an appropriate history has been made in the medical record (for adults).
21. There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines.
The words, phases and images should remain professional and demonstrate the following characteristics:
•Tactful tone
•Use of the most objective language possible
•Transparency
•Professional tone
1. Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont (Pa. : Township)). 2004 Nov;1(3):26-28. Available at: http://europepmc.org/article/PMC/3010959#free-full-text. Accessed 16 August 2024.
2. Set Forth the Basics of Good Medical Record Documentation. Available at: https://www.aapc.com/blog/. Accessed 16 August 2024.
3. Complying with Medical Record Documentation Requrements. Accessed 16 August 2024. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/certmedrecdoc-factsheet-icn909160.pdf.
4. Guidelines for Medical Record Documentation. Accessed 16 August 2024. Available at: https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
5. Importance of Preparing/Maintaining Legible Medical Records. Accessed 16 August 2024. Available at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/SE1237.pdf.