Ask ECRI: Keeping Medical Records Objective and Appropriate
April 26, 2017 | Ambulatory Care Risk Management
A risk manager recently asked ECRI Institute for clarification about the types of information that should be included in medical records. While reviewing records at her organization, the risk manager found information such as patient complaints, arguments between staff members, and notations of medication or vaccine errors, and sought information regarding whether this type of information should be included in the record.
In our response, ECRI Institute notes that medical records should include objective information pertinent to the patient's care. Therefore, documenting in the patient chart things such as arguments between staff is not an appropriate or acceptable practice. Documenting patient complaints would depend on the nature of the complaint; these can be documented briefly in a neutral and objective manner. With regard to errors in care, an objective description of the event and any follow-up care or treatment provided should be documented in...