The medical record is all of the written or electronic documentation relating to a patient. It includes past history information, current diagnosis and treatment, and correspondence relating to the patient. Billing information is often maintained in a separate accounting record. It is important to remember that the medical record is a legal document. Various laws cover the reporting, disclosure, and confidentiality of medical records. Thus, medical record management requires attention to accuracy, confidentiality, and proper filing and storage. Proper management is also necessary because the records may be subpoenaed, ordered by the court, during a malpractice case.
Each patient’s medical record contains essentially the same categories of material but with information unique to that patient. For example, not every patient has a consultation report from another physician or a surgical report. The format for the medical record reflects the physician’s specialty. An orthopedic surgeon, for instance, uses a format that includes questions pertaining to the patient’s mobility and pain level.
PURPOSE OF THE MEDICAL RECORD
Medical records serve multiple purposes. They provide a medical picture and record of the patient from birth to death. It is an important document for the continual management of a patient’s healthcare and furnishes documentary evidence of the course of evaluation and treatment. The patient record, which can result from a lifetime of medical visits, can assist the physician in diagnosing, treating, and tracking the patterns of the patient’s health. It also provides data and statistics on health matters such as births, deaths, and communicable diseases. A physician can track the ongoing patterns of the patient’s health through the medical record ( Figure 9.1 ).
The medical record is invaluable in an ambulatory healthcare or hospital setting as it provides the base for management of the patient’s care, alerts the physicians and staff to patterns and changes in patient responses, and provides data for research and education.
Figure 9.1 A Medical Records Filing System
In addition, because this legal document contains an objective, factual record of a patient’s medical condition and treatment, either the patient or the physician in a malpractice suit may use this information. Finally, the medical record is a legal document and, as such, should not contain flippant or unprofessional comments such as “The patient is very annoying.”
The medical record is a document that records both the care and treatment that a patient did and did not receive. The terms “medical record” and “medical chart” are used interchangeably.
The medical record serves as an important path for communication between medical personnel. In a case briefly discussed in Chapter 3 , Norton v. Argonaut Insurance Company, the medical record played a key role in documenting a medication error. A physician prescribed 2.5 c.c. of Elixir Pediatric Lanoxin, used to treat a heart condition, to be given orally to the baby by the infant’s mother while the baby was hospitalized. The doctor increased the baby’s Lanoxin dosage to 3.0 c.c. and told the mother about the new dosage. He signed a chart order that read, “Give 3.0 c.c. Lanoxin today for one dose only.” The mother gave the baby 3.0 c.c. as she was told to do by the doctor. A nurse, who was not familiar with the fact that the doctor allowed the mother to give the baby her medication, read the doctor’s order for 3.0 c.c. of Lanoxin to be given today. She then gave an injection of the drug to the baby not knowing that the mother had already administered the dose orally. This overdose of medication caused the baby’s death. In this case, the parents sued the doctor, nurse, and the hospital. In this landmark case, a nurse was held responsible for the infant’s death due to injecting a potentially lethal dose of a heart medication without questioning the prescribing physician. The physician’s order was unclear because he did not state that the mother would administer the 3.0 c.c. of Lanoxin orally (Norton v. Argonaut Ins. Co., 144 So. 2d 249, La. App. 1962).
CONTENTS OF THE MEDICAL RECORD
The medical record contains both personal information about the patient and medical or clinical notations supplied by the physician and other healthcare professionals caring for the patient. Personal patient information includes full name, address, telephone number, date of birth, marital status, employer, and insurance information. The clinical data or information includes all records of medical examinations, including x-rays, laboratory reports, and consent forms. The medical record will also contain any correspondence between the physician and the patient such as letters of withdrawal and consultation reports from other physicians. If a patient has provided informed consent for a procedure or test that has been explained to him or her, then a record of this explanation and the oral consent must be documented in the medical record.
As a legal document, both the defendant (physician) and plaintiff (patient) in a lawsuit can use the medical record. Because of its importance, some states have passed statutes that define what must be contained in the record. Many of these statutes reflect the accreditation requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare requirements as the minimum standard. Under these requirements, the medical record must include