The Medical Record

The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future.

It is a communication tool that not only provides clinical data regarding a patient’s current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, and to review utilization and quality of care.

The Contents of a Medical Record

* Face sheets, encounters for each visit
* Vital Signs
* Physician’s orders
* History and Physical forms
* List of Medical Problems
* Medication Lists
* Progress Notes
* Discharge Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory Testing
* Operative Reports
* Pathology Reports


Documentation is the most critical function regarding keeping accurate medical records, as it records all of the important details and facts regarding a patient’s care.


is legal documentation
includes a patient’s medical history
chronologically documents a patient’s care
allows physicians to plan and evaluate a patient’s care
provides continuity in care
allows all physicians involved in a patient’s care to communicate with each other
provides evidence of care provided in legal cases
assists in claims review and reimbursement
assists in meeting accreditation requirements

Centers for Medicare and Medicaid Services (CMS) regulations regarding documentation

Documentation MUST include:

evidence of a physical examination performed no more than seven days prior to admission or within 48
hours of admission

results from patient consultations and the findings from such evaluations

all orders, progress notes, medication records, radiology procedures and results, laboratory results,
and vital signs

the admitting diagnosis

a patient’s medical complications

any relevant risk factors

information that reflects the CPT/ICD-9 codes that were submitted to the patient’s insurance

consent forms signed by the patient

the discharge summary which summarizes the outcome of the admission, disposition of care, and
plans regarding follow up care

The S.O.A.P. Model


Subjective information includes information given directly by the patient, such as how they are feeling, their opinions on their care, and why they made the appointment. It represents the patient’s point of view of their condition.


Objective information represents the physician’s point of view. It includes information that was observed and measured by the physician during an examination or test.


The assessment identifies the main diagnosis that is specific to the visit, and includes the physician’s interpretation of that condition. When a patient has multiple diagnoses, a physician will dictate their assessment based on the patient’s complaint that particular day.


The “Plan” segment is when a physician makes a plan of action for a diagnosis, usually the condition specific to the visit of that day.

Challenges within Documentation

Every organization should ensure that each page within the medical record contains the patient’s name or identification number (the patients first and last name, first initial and last name, social security number, or personal identifier).

It is also necessary that all entries within the medical record include identification of the author.

Any known drug allergies should be prominently noticeable within the record, preferably on the front of the chart.

If any issues are unresolved from a previous visit, they should be addressed in subsequent visits.


The most common challenge within medical documentation is legibility. It is vital that the contents of the medical record are legible to someone other than the author because 1) documentation has a significant impact in resolving legal claims and 2) poor legibility can lead to misunderstandings (i.e. if a pharmacist misreads a prescription and dispenses the wrong drug to a patient).

It is recommended that organizations and physicians utilize transcription services. It is also recommended that organizations and physicians use computers to print orders and prescriptions.


Medical record entries should NOT include any gaps or inappropriate language. This would damage the integrity of the rest of the medical record.

Entries should NOT reflect judgment that something unexpected happened. Words such as “unintentionally”, “inadvertently”, and “unexpectedly” should NOT be used within dictations.

Entries should also NOT use words that are unspecific and cause doubt, especially in the case of a legal claim. Words like “appeared” and “apparently” should NOT be used.

Entries should NOT contain ambiguous words or phrases such as “doing well” or “eating better”.

Claims Reimbursement

Documentation is the best support in proving “medical necessity”. Poor or minimal documentation can lead to the denial of a claim.

Documentation Rules

Correcting Errors

To correct an error within an entry, the author must draw a single line through it so that the original content is still visible. If there error is completely covered or blacked out, it will cause concern and the worst may be assumed of what it may have been. The correct documentation should then be written above the error and should be signed, dated, and the reason for the correction should be noted.


Any statement made by anyone other than the author of the entry, should NOT be documented as if it were fact. The source of the statement should be noted and the statement itself should be in quotation marks.

Telephone Calls

Under no circumstances should medical advice be given over the phone unless it is certain who is on the other end of the call. There should be policies in place that dictate who may give advice over the phone (i.e. nurses, physicians… NOT receptionists) and what the limits are of what type of advice someone other than the physician may provide.

ALL phone conversations should be documented and placed in chronological order within the medical record.


A countersignature is a signature from a physician who reviews a record after the primary physician has signed it. The countersignature implies that the physician understands and agrees with the care described by the dictating physician.

It is important to acknowledge, that when a provider signs an entry within a medical record, that they are responsible for whatever is contained in the entry.


Although abbreviations save time, many are ambiguous and can be misinterpreted by other physicians. Only standard abbreviations should be used to avoid any misinterpretation.

Documenting the Termination of a Physician/Patient Relationship

ALL issues of patient Cliniverse Research non-compliance should be objectively documented within the medical record. Any action taken, reinforcement or education, should also be noted.

When a physician intends to notify the patient of the termination, they should be told verbally. A certified letter should then be sent to the patient outlining the reasons of termination and time frame in which the relationship will terminate. A copy of the certified letter should also be kept within the record.

Record Retention

The length of time in which medical records must be retained differentiates between statute of limitation regulations and individual state statutes.

However, everyone organization MUST enforce clear policies and procedures regarding maintaining and retaining medical records.

Release of Records

Records may only be release as authorized by individual state and federal laws.

Organizations must also have clear policies regarding the release of medical records that should determine:

* who may request and receive a copy of a patient’s medical record
* who is authorized to release medical records and to what parties
* how the practice will protect protected health information
* how releases of records will be monitored and documented

Strong policies on the above greatly assist in avoiding liability.

Ownership of Records

The ownership of medical records is a unique situation, as both the patient and the medical facility have ownership interests. The facility owns the physical record however the patient owns the information within the record.

Therefore, the record MUST remain within the medical facility, and the facility should ensure that the patient’s information is protected.

Patients have the right to any information within their record, however such rights differentiate between states.


When legal claims arise, medical documentation is relied upon to determine the standard of care that was provided. Little or no documentation regarding the course of treatment strongly supports the claim of negligence.

Medical records may expose:

– the series of events that led to a patient’s injury and subsequent claim

– inefficient use of information within the medical record

– poor communication from on doctor or department to another

– illegible records or orders is a comprehensive website addressing managing a medical facility. iPracticeConsultant focuses on the financial aspects of operating a medical facility, human resources guidelines in managing staff, marketing information specific to healthcare, and healthcare risk management. iPracticeConsultant also provides various financial calculators to allow managers to conduct quick and accurate financial analysis.

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