Medical Record Documentation Guidelines to Avoid Legal Risks Irregularities in the medical record emerge during a medical chart review. Physicians must be careful when preparing the medical chart.
Documentation in the medical record is of immense significance in the legal system and the failure to document pertinent information is regarded as a major breach and a deviation from the accepted standard of care. Missing medical details, erratic data and so on are identified during medical chart reviews performed for legal purposes. Wrong information as well as missing information could result in negative patient outcomes including injury or even death. Proper documentation can help avoid negative legal repercussions. Legal risks are not the only reason that necessitates accurate medical chart documentation. The medical record represents the entire medical history of the person, and is very significant from the point of view of ongoing care, research, and quality assurance. Therefore, the
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medical record of a patient must be complete, error-free, confidential, timely, and appropriate. When preparing the medical chart, it is important to consider who all are likely to access and read the record. These would include members of the care team, physicians on call, ER physicians, medical peer review physicians, insurers, attorneys, and quality assurance reviewers. With the introduction of the EHR, and the trend of encouraging patient participation in their care, patients also may be viewing their medical record. By keeping the possible audience in mind when creating the record, physicians can ensure clarity and an easily understandable style of communication, which are vital as regards liability prevention as well as optimum patient care. The NCQA (National Committee for Quality Assurance) has outlined a set of commonly accepted standards for medical record documentation. Among these six are to be considered core components: 1. Significant illnesses and medical conditions must be indicated on the problem list. 2. Medication allergies and adverse reactions must be clearly noted in the medical record. If the patient has no known allergies or history of adverse reactions, this must be properly noted in the record. 3. For patients seen three or more times, their past medical history must be easily identified and include serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses. 4. Working diagnoses must be consistent with findings. 5. Treatment plans must be consistent with diagnoses. 6. There should be no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. Apart from these 6 core components, there are other elements required for consistent, current and complete documentation. The patient’s name or ID number must be included on each page, and personal biographical data must include the address, employer, home and work telephone numbers and marital status. Ideally, all entries in the record must be dated, and contain the author’s identification in
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the form of a handwritten signature, initials or unique electronic identifier. The medical record must be intelligible to someone other than the writer. Any applicable subjective and objective information pertinent to the patient’s presenting complaints must be identified in the history and physical examination. The medical record should also show that laboratory and other studies ordered are appropriate. Patient encounter forms and notes should record follow-up care, visits or calls (in months or weeks) when indicated. Also, the medical chart should show that any unresolved problems from earlier office visits are addressed in the follow-up visits. In case a consultation is requested, there should be a note from the consultant included in the medical record. The practitioner who ordered consultation, lab tests, or imaging tests must initial the respective reports filed in the chart. All the above elements are relevant from a legal perspective, and may be focused on during a medical record review performed for medical malpractice litigation, or other investigative evaluations. The attorneys defending the accused physician can make their inferences only from the documentation provided in the medical chart. This brings home the importance of sensible charting techniques, and why clinicians must focus more on appropriate medical charting. Proper documentation reduces the chance of malpractice lawsuits and risk to the patient.
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