PHYSICIANS' RECIPROCAL INSURERS
Risk Management Department
Loss Prevention Technique © 1987

While it is certainly true that medical records are established and maintained primarily as a means of communication for planning patient care and keeping all those participating in the patient's care informed, they are also of vital importance in cases where medical malpractice is alleged. A compilation of brief, incomplete notes that are poorly organized does not serve any of these functions.

While specific documentation requirements vary with the physician's specialty, these guidelines should be helpful in the maintenance of comprehensive patient care records.

1. Record Format
A chart that appears to be put together in a haphazard fashion is often equated with haphazard care.
Time and effort expended in establishing a specific format for the various components of the chart, will also yield rewards in the time taken to locate specific sheets when they are needed.
Also, it is recommended that the sheets in the records be secured to the record jacket. Loose sheets are, of course, more easily lost.

2. The Use of Forms in the Office Chart
Thoughtfully prepared forms are an excellent tool in effective record keeping. Whether the physician chooses to compile his or her own forms or purchase commercially prepared ones, once these forms are put into use, they should be completed in their entirety since to choose to use a certain form is essentially to state that the information it requires is important.
Where physicians develop their own forms, the forms should have a caption and should be appropriately labeled with the physician's/practice's name and address.
There should be consistency in the type of sheets used for documentation of office visits. Frequently, various kinds of miscellaneous sheets are used in a single record. This gives the office chart an unprofessional appearance.

3. Be Sure to Record a Complete Patient History/Summary
While it is understood that the requirements regarding the level of detail needed in a history varies with the specialty, in general, the following basic areas should be covered in a physician's documentation of a patient's history:
• Surgical conditions
• Medical conditions
• Allergies and/or untoward reactions to drugs
• Currently or recently used medications
• Conditions that could significantly influence future care, e.g. family history, social history.
Where the patient denies any of these, the record should specifically document that.

4. The Date is Important
Every chart entry must begin with a complete date including the year. The date that treatment was rendered is always important.

5. Include a Chief Complaint/Purpose of Visit in Your Notes
In compiling a comprehensive patient care record it is important that the findings at each visit are prefaced with a statement of the reason that the patient presented and any symptoms or complaints that are reported to the physician, including the history of the present illness.

6. Record the Details of the Physical Examination/Clinical Findings
In recording the finding of the physical examination, the physician must be sure to be specific in his/her recording of all areas examined. Where the findings are negative, that fact must also be recorded.
For example, a gynecologist performs a breast exam on a patient and fords that it is within normal limits and, therefore, neglects to record anything concerning this examination. The patient subsequently discovers a breast mass which is found to be malignant. One can be certain that an adversary will not accept the explanation that the exam was done at all.

7. State Your Diagnosis/Medical Impression
Frequently in our review of records it is noted that a diagnosis or medical impression is not clearly and specifically stated. Of course, this is an important component of a comprehensive medical record.

8. Were Any Studies Ordered?
Where diagnostic studies are required, that should be entered into the patient's record. There should be no question concerning what tests the physician has ordered for a particular patient.

9. Were Any Therapies Prescribed?
Any treatment that is prescribed (whether it is a prescription or over-the-counter drug or attendance at physical therapy sessions), must be entered into the medical record.

10. The Plan of Care for the Patient (Disposition/Recommendations)
The plan of care for the patient as well as any recommendations and instructions given to him/ her must also be recorded. This should include the time frame within which the patient is expected to return to the office.

11. Document Telephone Advice
Advice given to patients by telephone should be noted in the chart. There are several cases of which we are aware, in which the defense of the case rests squarely upon a telephone conversation between doctors and their patients. This information can be invaluable.

12. Are Your Records Legible?
Of course, to document all of the foregoing in an illegible manner is ineffective. It is of great importance that medical records are written legibly.

13. Dictated Notes
Notes that are dictated and transcribed should be read and signed prior to being incorporated into the medical record. This is important because on occasion a typist may not record the information as the doctor intended. The re-reading gives the doctor an opportunity to ensure the accuracy of the note.

14. Carefully Document Informed Consent Discussion
In addition to any required consent forms, the physician's notes should reflect a discussion of any proposed surgical procedure with the patient. This comprehensive note should indicate that the risks, benefits and alternatives of the procedure have been discussed with the patient.
(Refer to PRI's brochure - Loss Prevention Techniques - On Obtaining Informed Consent, May/June 1986.)

15. Identify Chart Entries With Your Signature
Especially where there is more than one physician in a practice, it is important that medical record entries are signed. This is also a good procedure for nurses and others who write notes in the chart.

16. "No Shows" and Cancellations - Make Note of Them
For patients who do not present for their scheduled appointments, there should be notation made in the record, as well as of any efforts made to contact these patients.
In many instances, where a noncompliant patient is involved, it is just such a record that takes the onus off the physician, if medical malpractice is alleged.

17. Request and Maintain Summaries of Care Rendered Elsewhere
For a new patient, records should be requested from previous health care providers where it is deemed necessary for the continuity of care. For a patient who is referred for a consultation or testing at another facility, the physician should always obtain summaries/ reports of such treatment or testing to be incorporated into his/her own record.

Below is a list of our Loss-Prevention Techniques:

Telephone Matters | Patient Relations | Test Results and Follow-up Monitoring Patients | Patient Follow-up
Guidelines for Comprehensive Office Chart
Emergency Prepardness | Developing Telephone Protocols
Medical Office Personnel | Medication Matters
Issues in Physician Coverage
Discounting the Doctor/Patient Relationship