Medical record documentation is of prime significance when it comes to patient care provision and successful coordination of care. Physicians are expected to maintain medical records in a manner that is organized and up-to-date so that any medical record review for quality purposes can be easily and effectively carried out. Let us consider the important details medical records should contain.
- The patient name or ID should be present in every page of the record.
- Notes dictated should be initialed to make sure they have been reviewed.
- Make sure that all presenting symptom entries including phone entries are legible, dated and signed.
- Adverse reactions, allergies/NKDA should be clearly displayed in a dedicated location.
- For patients with ongoing or chronic conditions, a medication list must be maintained and regularly updated.
- Maintaining an updated problem list for significant medical conditions/illnesses is vital.
- History and physical exam documentation should contain all subjective and objective information applicable to the patient’s presenting symptoms. The treatment plan documentation should be consistent with the findings.
- The documentation should prove continuity and coordination of care between the primary care physician, specialty physician and/or facilities if there is a reference to referral or care provided elsewhere.
- The medical record reviewer will be looking for a discharge summary or a summary of findings in the medical record. Reports they will be considering include discharge summary following outpatient surgery or inpatient care, reports/progress notes from consultants, physical therapy reports and home health provider/nursing reports.
- Details regarding lab tests and other studies ordered should be entered in the medical chart, along with results. There should be evidence of documentation of follow-up recommendations and/or non compliance to the care plan.
- For adult patients, it is important to document Advance Directive/Living Will/Power of Attorney discussion. Copies of executed documents should be attached.
- Ensure that all routine preventive services and risk screenings are meticulously noted. These include childhood immunizations, adult immunizations, pap tests, mammograms and so on. If the patient, parent or legal guardian has expressed their refusal to comply with these services, it should also be recorded.
Medical records are very important for all providers that are involved in a patient’s care. They justify the need for particular treatments, show what services were rendered and whether they were medically necessary. Maintaining medical records with the expected standards is of utmost importance in the current healthcare scenario featuring multi-specialty care and multiple providers.