Documentation and Patient Medical Records

 Periodic review of patient office records should be conducted using the following criteria:

 

(a)

 

Accuracy – Analyze for inconsistencies and incompleteness in clinical facts, findings, test results, and the like. Dictated notes and reports should be dated and proofread to ensure accuracy and completeness.

(b)

 


Objectivity – Identify subjective or personal remarks or notations about the patient not clearly supported by documented facts; identify clinical findings or diagnoses not supported in context by objective data or earlier noted observations in the record; identify subjective comments about the care of other providers.


(c)

 


Legibility – Identify obliterations or changes made in the record inconsistent with appropriate hospital medical records documentation standards, such as the rendering of prior entries unreadable or failure to initial and date appropriate changes and new entries.
(d)



.
Timeliness – Review the timeliness of entries following patient office encounters. Assess the appropriateness of late entries. It is suggested that records be prepared as contemporaneously with treatment as possible and, if appropriate, dictated in the presence of the patients. Also review, for completeness and timeliness of receipt and filing, laboratory and other documentation of the review by the treating/attending physician.
(e)


Comprehensiveness – Identify conclusions charted without documentation of rationale or intermediate clinical steps; identify critical decision points where the physician’s clinical assessment or reasons for making the decision are not documented

(f)

 


Alterations – Examine for missing pages, erasures or other inappropriate alterations, including sections of the record which may have been removed, as well as missing items like lab test reports, radiology films, or EKG strips. Any additions or corrections to the record must be dated and signed, and the date must reflect the day of the addition or correction, not the date of the original entry being modified.

 

NOTE: This procedure should be designed and carried out in the manner which maintains the strict confidentiality of patient records. Appropriate legal and/or risk management consultation should be obtained when necessary.

Physicians should keep original medical records in their possession.

Commentary:

Although the information contained in the medical record belongs to the patient, the physical record itself belongs to the physician. Physicians should provide a copy or summary of the record but always maintain the original in their possession. Physicians should be aware of state laws addressing retention of and access to medical records and physician office records.

 Physicians should provide patients with access to their medical records subject to provisions of state law. If the law is silence as to such access, record, but only upon written request signed by the patient.

A copy or summary of a patient’s office record should be released pursuant to an attorney’s request only after:

(a)
The patient’s physician has reviewed the record and request;
(b)


The request has been accompanied by a written authorization dated and signed by the patient, or made pursuant to a court mandate (physicians are encouraged to first consult their attorney when presented with a court order to produce patient’s records);
(c)
The medical liability insurance carrier for the physician or office practice has been consulted when there is any indication that the request for the records is being made by the attorney for the purpose of evaluating a potential legal action against the physician.

Appropriate post-treatment and continuing care instructions should be provided by patients, and should be documented in the record. It is preferable that such instructions be provided in writing, particularly when the instructions are part of a formal treatment plan.

Commentary:

There is a growing number of large medical liability judgements and awards arising from claim where defendants physicians fail to produce documented evidence of appropriate discharge or post-treatment continuing care instructions. Although most patients are provided with specific instructions before they leave the physicians office, documentation of such advice or warnings is seldom incorporated in the patient’s record or, more importantly, provided to patients in writing. Some practice settings that use routine written discharge/continuing care instruction forms require the patients sign the form, a copy of which is retained in the medical record.