Medical records contain important information regarding the patient and the medical care he/she receives from the medical team. While primarily important from the viewpoint of ensuring appropriate medical services and care for the patient, the medical record is also a legal document. These healthcare documents are required for processes such as medical peer review for insurance eligibility determination. The information contained in the medical record comprising patient identification data and clinical data must be kept confidential, when it is used for medical chart reviews for medical or legal purposes. The identification data includes demographic details such as name of the patient, sex, age and so on, and does not particularly relate to the treatments or care provided by the physician or healthcare facility. Clinical data includes all information related to the patient’s diagnosis and treatment such as notes or records generated by doctors, nurses and other clinicians; results of tests, and so on.
While the medical record is a highly sensitive and confidential document, there are occasions when the records need to be released for various purposes. Typically, medical record requests come from the patients and their relatives; medical staff members, other physicians and healthcare facilities concerned with the care of the patients; and third-party payers, government and other agencies. When such requests are made, the medical records may be released with proper authorization from the patient himself/herself or their legally qualified representative.
Healthcare providers must ensure that the medical records clearly and completely document the progress of a patient’s care. All medical decisions taken and the evidence on which those decisions were based must be recorded. This information should be clearly communicated to any physician or provider who might treat the patient in the future. This is important from a medical point of view. From a legal viewpoint good record keeping will work in the provider’s favor if he/she needs to respond to or defend against a complaint or claim. In claims filed for negligence, contemporary records of all decisions made about a patient’s care and why those decisions were made are vital.
What Constitutes a Good Medical Record?
Firstly, a good medical record should be comprehensive and accessible, legible and properly dated. Good note taking is very important. The following aspects should be clearly recorded.
- History: This refers to the condition of the patient and relevant past history including concurrent illnesses, medications prescribed, and allergies if any.
- Examination: Must contain all positive and applicable negative findings, all pertinent observations and measurements including temperature, blood pressure, and pulse.
- Diagnosis: The diagnosis made must be accurately recorded, showing the reason for making such a diagnosis. Any differentials or uncertainties must be clearly recorded.
- Investigations: These should include all imaging tests such as X-rays or scans, and all lab results.
- Medication Management: These records should provide information regarding the drugs prescribed and administered with dosage. Information about other treatments such as physiotherapy must also be given.
- Referral and Follow-Up: Any follow-up tests recommended, future appointments made, and referrals must be mentioned clearly.
- Patient Education: Here all details of discussions with the patient regarding risks and benefits of the treatment, treatment plan, prognosis, and potential complications should be recorded.
- Patient Consent: The consent given by the patient must be recorded, making sure that it takes into account all the above-mentioned aspects.
When considering the medical record as a legal document, complete and accurate records are the best alibi for the provider and can stop a medico-legal claim from proceeding any further. Well-recorded patient records will contain answers to the fundamental questions such as who (details of the patient who was provided the treatment or service), when (the date and time when the patient was seen or when a test or other procedure was undertaken, or a treatment given), what (what was done, said, observed, instructed, or checked) and why (justification regarding why the decisions were taken with regard to patient care).
An important thing for providers to note is that any improper alteration of the medical records with a view to mislead the parties and the court in legal proceedings could lead to serious admonishment by a court. It could also prove to be the ground for regulatory criticism on occasions where there is a duty to maintain accurate medical records.
The medical records must display consistency of recording if they are to prove useful when defending a case. When the medical record is clear, it would give a better understanding regarding the entirety of patient care. It will then be more useful to the medical team treating the patient; it will be more meaningful to the patient himself/herself; it will be more meaningful to any court or tribunal that wants to understand the care received by the patient; and it will be more meaningful for a defendant healthcare provider who needs to defend or explain their actions towards their patient at any time.
Given the importance of the medical record as a legal document, here are some things healthcare providers need to consider.
- Whether the medical records are all maintained in the formal clinical record and whether any record is maintained outside of that formal clinical record.
- Whether outpatient appointments are recorded accurately and efficiently.
- Whether a written record of patient consultations and follow-up instructions are maintained.
- Whether the material risks of a procedure have been discussed with the patient at their outpatient clinic and whether these discussions have been clearly documented in the medical record.
- Whether all details of consultations with the patients are recorded in the written or electronic medical record.
- Whether the actions taken on receiving lab test results, and other investigative exams have been correctly recorded.
- Whether all follow-up instructions and information including those the patient should follow up with the provider at a certain time have been recorded.
- Whether standard and appropriate abbreviations are used in the clinical records so that it can be understood by other practitioners.
- Whether the medical records are appropriately dated, signed and the time recorded correctly.
- Whether the medical records are factual and objective, and not subjective.
As mentioned earlier, medical records are important evidence in medical negligence and injury claims and must therefore be carefully written and maintained. During a medical record review, the medical chart should provide clear, accurate, chronological, consistent and complete details about the patient care provided. Any healthcare provider must ensure that the patient medical record remains the best evidence for medical – legal purposes, while also making available all medical information that is necessary to make sure that the patient receives the best treatment and care.