Medical Records

March 1, 2008 | Healthcare Risk, Quality, & Safety Guidance

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The medical record,* whether electronic, paper, or a hybrid of both, is a collection of facts and observations about the patient’s health history, including illnesses; tests, procedures, and treatments performed or provided; and the results of these tests, procedures, and treatments. It is the principal means by which patient information is exchanged among physicians and other healthcare providers and helps facilitate appropriate and timely care.

_______________ * The liability issues and recommendations discussed in this article apply to medical records in any form, paper or electronic. Issues specific to electronic medical records are addressed in Electronic Health Records. _______________

The information contained in a patient’s medical record may be used for medical and nursing audits or peer-review evaluations, to gather clinical data, to justify reimbursement, and to document fulfillment of regulatory, accreditation, and licensure requirements (Johnson et al.). The medical record also provides evidence of a systematic plan of treatment and, in a medical malpractice case, serves to document the care rendered to the patient. Because such cases are often litigated years after treatment—and because healthcare providers may be unavailable or unable to testify or may not remember important facts about the case—jurors may consider the medical record to be a more reliable account of the patient’s healthcare during the hospitalization than any other source.

Although the facility’s health information manage-ment (HIM) professional is the custodian of the medical record and is responsible for attesting that the record has been kept in the normal course of business, risk managers should be thoroughly educated about their facility’s HIM process, including the basic components of each medical record, the methods used by staff to document or chart patient care, the signs that indicate poor charting practices, and potential areas of liability created by poor medical record practices. This Risk Analysis focuses primarily on paper-based medical records and reviews the following:

Medical record requirements are established by federal regulations and state statutes, as...

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