To be absolutely safe, all medical records should be retained ________.

Chapter 9

The Medical Record

Learning Objectives

After completing this chapter, you will be able to:

· 1. Define the key terms.

· 2. List five purposes of the medical record.

· 3. List seven requirements for maintaining medical records as recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

· 4. Discuss guidelines for effective charting.

· 5. Discuss what is meant by timeliness of charting and why it is important in a legal context.

· 6. Describe ways to protect patient confidentiality that relate to the use of fax, copiers, e-mail, and computers.

· 7. Discuss the time periods for retaining adults’ and minors’ medical records, fetal heart monitor records, and records of birth, death, and surgical procedures.

· 8. Explain 13 guidelines to follow when a subpoena duces tecum is in effect.

· 9. Describe confidentiality obligations using electronic medical record keeping.

Key Terms

Credibility gap

Credible

Disclosed

Doctrine of professional discretion

Electronic medical record (EMR)

Encryptions

Firewalls

Medical record

Microfiche

Open-record laws

Privileged communication

Protocol

Public Health Services Act

Timeliness of documentation

THE CASE OF ANESHA AND THE LOST MEDICAL RECORD

Anesha’s 15-year-old daughter, Robin, is experiencing abdominal pain when exercising during her gym class. After reviewing the results of several tests, Robin’s pediatrician still cannot determine the cause of Robin’s abdominal pains. He asks Anesha if she had any obstetrical problems when she was pregnant with Robin. Anesha had just read a report in a national newspaper discussing the use of a hormonal treatment to control bleeding that was used on expectant mothers at about the time that Anesha was pregnant with Robin. The report stated that female children could develop serious uterine problems, including cancer, during their adolescence if their mothers were given a particular hormone during their pregnancy that was in use 15 to 20 years ago. The report went on to state that male children were unaffected. Anesha recalled that her obstetrician, Dr. C., had given her that particular hormone medication to control bleeding during her pregnancy with Robin and also when she was expecting Robin’s brother, Sam. Anesha wrote Dr. C. to request her medical record and ask if the doctor had prescribed the hormone treatment during her pregnancy. She received a letter stating that Dr. C. could not recall what he prescribed 15 or 16 years previously. The letter also stated that all his records were destroyed in a fire five years ago.

· 1. What should Anesha tell Robin’s pediatrician?

· 2. What does Robin need to know about her potential for a serious uterine diagnosis?

· 3. How could this situation have been prevented?

Introduction

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.”

MED TIP

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

· Admitting diagnosis.

· Evidence of a physician examination, including a health history, not more than seven days before admission or 48 hours after admission to a hospital.

· Documentation of any complications such as hospital-acquired infections or unfavorable medication reactions.

· Signed consent forms for all treatments and procedures.

· Consultation reports from any other physicians brought in on the case.

· All physicians’ notes, nurses’ notes, treatment reports, medication records, radiology and laboratory reports, and any other information used to monitor the patient.

· Discharge summary, with follow-up care noted.

The components of a standard medical record are listed in Table 9.1 .

MED TIP

Document patient comments such as “I’m all alone” or “I just feel I can’t go on.” Any comments of this nature should be relayed to the physician because they may indicate an emotional problem in addition to the physical one for which the patient is seeking treatment.

TABLE 9.1 Standard Medical Record

Patient’s complete name, address, home and work telephone numbers, Social Security number, birth date, and marital status

Patient’s past medical history

Dates and times of all medical appointments and treatments

History of present illness

Review of symptoms, reason for appointment

Chief complaints (CC)

Results of physical examination performed by physician

Physician’s assessment, diagnosis, and recommendations for treatment

Progress notes from past visits and treatments

Family medical history

Personal history

Medication history with notations of all refill orders

Treatments

X-ray reports

Laboratory test results

Consultation (referral) reports

Diagnosis

Other patient-related correspondence:

· Informed consent documentation, when appropriate

· Signature for release of information

· Copy of living will

Documentation of all prescriptions and authorization for refill orders

Documentation of dates when the medical record (or portions) is copied, including to whom it was sent

Documentation of any missed appointments and the subsequent action taken, such as follow-up telephone calls

Instructions concerning diet, home care, exercise, and follow-up appointments

Hospital clinical records will also include:

· Nurses’ notes (observations by the nursing staff)

· Operative report

· Delivery record

· Anesthesia reports

· Medication and treatment records

· Social service reports

· Physical therapy notes and reports

· Dietary notes and reports

· Fluid intake and output (I & O) charts

· Discharge summary

The medical record should never contain irrelevant material that is not related to the patient or the patient’s care. All healthcare personnel who provide care must document that care or treatment and then sign their name to the documentation. No personnel may sign any name other than their own. In addition, not all healthcare professionals will chart information on a patient’s medical record.

Table 9.2 provides guidelines for charting.

TABLE 9.2 Guidelines for Charting

· 1. Always double check to make sure that you have the correct chart.

· 2. Use dark ink, preferably black, and write legibly. Printing is preferred if one’s handwriting is difficult to read.

· 3. The patient’s name and identification number should appear on each page. A stamping device can be used for this purpose.

· 4. Every entry must be dated and signed by the person writing the record. If initials are used then the person’s entire signature must be either in the medical record or on file in the medical office or institution. No one can sign for anyone else.

· 5. Entries should be brief but complete.

· 6. Use only accepted medical abbreviations known by the general staff.

· 7. Correctly spell all medical terms.

· 8. Never erase or use a liquid eraser, or in any way remove information from a medical record.

· 9. Never leave spaces for someone to add later charting.

· 10. Document all telephone calls and correspondence relating to the patient.

· 11. Document all action(s) taken as a result of telephone conversations.

· 12. Document all missed appointments.

· 13. Document all incidents of noncompliance.

· 14. Document all patient education.

· 15. Do not record any personal opinions, speculations, or judgments.

Corrections and Alterations

Some medical record errors are unavoidable. These might include errors in spelling, transcription, or inadvertently omitted information or test results. Occasionally, an error occurs when patient information is written in the wrong chart. It is perfectly acceptable to correct these errors as long as this is done properly. Nothing should be deleted. All corrections on paper files should be made by drawing a single line through the error, writing the correction above the error, dating the change, and then initialing it. Do not erase or use correction fluid. The original statement or error should never be obliterated. Many healthcare professionals will also note in the margin of the record why the change was made, as for example, “incorrect chart.” See Figure 9.2 for an example of a corrected chart notation.

MED TIP

Use only black or blue ink when charting in a medical record. Never use pencil or colored ink pens.

Electronic medical record (EMR) corrections are handled very differently than the paper record corrections. Each facility, depending on their software program, will have their own guidelines, or protocol , for correcting errors. One example occurs when an addendum, or revision, must be added after the date of the original entry. For example, in a medical office if a patient is unable to provide a urine sample on the day of his or her exam but brings one in the following day, a CMA or RN can draft a temporary revision or addition to the medical record, such as a test result, along with the notation “revision” and their name. The physician, who is the only authorized person, in this case, to permanently add or change the electronic record, will then go into the program and approve the revision and sign it, making it a permanent part of the record. Therefore, all needed revisions must be brought to the attention of the physician when using this software system. Any time this record is examined the word “revision” will show up. All entries should be double-checked before transmitting the information. The user should sign-off all electronic patient records when not in use.

While it is acceptable to make an immediate correction in a medical record, it should never be altered. In one case, the plaintiff’s attorney waited several weeks after the defendant was found not guilty and requested the medical record a second time. He noted that it had been altered after the case was closed. Upon review of the case, the judge ordered punitive damages.

Figure 9.2 Example of Corrected Chart Notation

Falsification of medical records is grounds for criminal indictment. In a New York case, two orthopedic surgeons performed a procedure on a patient that required implanting a prosthetic device into the hip joint. The salesman of the prosthetic device was in the operating room when the patient had to be reopened in order to correct the placement of the device. One of the surgeons left the operating room to return to his office and agreed that the salesman could assist the remaining surgeon. The salesman assisted by removing the prosthesis from the patient and preparing it for the surgeon to re-implant. The surgeon who left the operating room was sued for malpractice because the surgical record did not show that he had been replaced with a nonphysician during the surgery. The hospital and surgical nurse were also indicted for violating a duty imposed on them by the nature of their profession (People v. Smithtown Gen. Hosp. 736, 402 N.Y.S.2d 318, Sup. Ct. 1978).

Normal, as well as abnormal or negative, findings should all be noted in the medical record. Some doctors and staff become hurried and document only the abnormal. This can result in a problem if the medical record becomes part of a court record. If a jury does not see a test or procedure documented, then they tend to assume that it was not done no matter how strongly the physician or healthcare provider asserts that it was.

MED TIP

It is almost impossible to hide a change in a medical record as handwriting, type of ink, and paper used can all be detected through scientific testing.

Timeliness of Documentation

Medical records must be accurate and timely. Timeliness of documentation means that all entries should be made as they occur or as soon as possible afterward. Federal reimbursement guidelines mandate that all medical records should be completed within 30 days following the patient’s discharge from a hospital. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an agency that oversees hospital accreditation standards, also has issued guidelines for timeliness in charting.

Late entries into the medical chart mean that, even for a brief period of time, the medical record is incomplete. This can cause a serious problem if the incomplete record is subpoenaed for a malpractice suit. Any entry made into a medical record after a lawsuit is threatened or filed is suspect. Also, if the medical record is not updated promptly, there could be a lapse of memory about what actually occurred.

Completeness of Entries

The medical record may be the most important document in a malpractice suit because it documents the type and amount of patient care that was given. If the medical record is incomplete, the physician or other healthcare provider may be unable to defend allegations of malpractice, even if there was no negligence. For instance, in a 1985 Missouri case, a physician ordered that a patient be turned every two hours. The attending nurses, however, failed to note in the patient’s record when they turned her. The patient claimed that she had not been turned as ordered and that this caused her to develop serious bedsores, which led to the amputation of one leg. The nurses presented an expert witness who testified that in some instances nurses become so busy that they place the needs of the patient, such as turning, before the need to document. The court eventually dismissed this case. However, not all such cases are dismissed (Hurlock v. Park Lane Med. Ctr. Inc., 709 S.W.2d 872, Mo. Ct. App. 1985).

MED TIP

The medical record is a legal document and as such can be subpoenaed into court as evidence in a malpractice case.

In a California case, an appeals court ruled that the physician’s inability to provide the patient’s medical record created the inference of guilt. (Thor v. Boska, 113 Cal. Rptr. 296, Ct. App. 1974.) This is an example of a situation in which the physician may not have been at fault. However, the fact that he was unable to provide any documentation about his treatment of the patient meant that even at the appeals court level, he did not win his case.

MED TIP