The Medical Record


the medical record is one of, if not the most important documents in the delivery of healthcare services.It is what drives the progress of patients care. It allows the doctor to review the patient’s medical history as well as plan a course of care for the future.

it is a communication tool that not only provides clinical data on current and past medical history of the patient, but is also used in the review and refund insurance claims, and to review the use and quality of service.

content Medical Record

* Face sheets, encounters for each visit

* Vital Signs

* orders medical

* History and physical form

* List of medical problems

* administration Lists

* Progress Notes

* Discharge Summary

* authorization forms

* Diagnostic Testing

* Laboratory Testing

* Operative Reports

* Pathology Reports


Documentation is the most critical role for keeping accurate medical records, as it records all the important information and facts about the care of the patient.


is legal documents

includes a patient’s medical history

chronology documents patient care

allow doctors to organize and evaluate patient care

provides continuity of care

makes all physicians involved in the care of the patient to communicate with each other

gives evidence of care provided in legal matters

assistance required review and refund

aid meeting accreditation requirements

Centers for Medicare and Medicaid Services (CMS) regulations regarding documentation

Documentation must include:

evidence of medical tests performed more than seven days for admission or within 48

hours of admission

Results from patient consultations and the results of such assessments

all orders, progress notes, medication records, radiology procedures and results in the laboratory,

and vital signs

Recognizing analysis

complications the patient

all relevant factors

information reflects CPT / ICD-9 codes submitted collateral patient

consent forms signed by the patient

discharge summary that summarizes the outcome of the collection, disposal and care

plans for follow-up care

The SOAP Model


Subjective data are given directly by the patient, such as how they feel, their views on their care, and why they made the appointment. It represents the point of the patient examination condition.


objective information represents the physician point of view. It includes information was seen and recommended by a doctor during an examination or test.


Assessment identifies the main diagnosis that is specific visit, covering medical interpretation of the situation. When the patient has multiple diagnoses, the doctor will order their food based on the complaints of patients that particular day.


The “Plan” part is when a doctor makes an action for analysis, usually the condition specific to visit that day.

Challenges within Documentation

Each institution shall ensure that each site within the medical record contains the name or identification number of the patient (patient first and last name, first initial and last name, ID number, or personal identification) .

It is also necessary that all entries in the medical record is the identification of the author.

Any known drug allergies should be prominently noticeable within the record, preferably on the face of the chart.

If some issues are unresolved from the previous visit, they should be addressed in subsequent visits.


The most common challenge within the medical documentation is legibility. It is important that the content of medical records are legible other than the writer because 1) Data has significant influence to resolve disputes and 2) poor legibility can lead to misunderstandings (ie if the pharmacist misread the prescription and dosage wrong medicine to the patient).

It is recommended that organizations and physicians utilize transcription services. It is also recommended that organizations and physicians use computers to print orders and prescriptions.


medical records records shall not include any gaps or inappropriate language. This would harm the integrity of the rest of the medical records.

Entries not reflect its assessment that something unexpected happened. Words such as “accidental”, “surprising” and “unexpected” Do not use in dictation.

Entries should also not use words that are unspecific and cause doubt, especially in the case of a legal claim. Words such as “will” and “appears” should not be used.

Entries should not contain ambiguous words or phrases such as “doing well” or “eat better”.

Claims Refund

Documentation is the best support in proving “medical necessity”. Poor or low documentation may lead to rejection of the claim.

Documentation Rules

correct errors

To correct an error in translation, the author must draw a line through it so that the original material is still visible. If the error is completely covered or blacked out, it will cause concern and the worst can be expected for what it may have been. Correct data should then write the above error and must be signed, dated, and the reason for the correction should be noted.


Any statement made by someone other than the author of the entry should not documented as if it were fact. The source of the statement should be noted and the statement itself should be in quotation marks.


Under no circumstances should the doctor be given over the phone unless it is certain that at the other end of the call. There should be rules that dictate who may give advice over the phone (ie nurses, doctors … no receptionist) and what restrictions on the type of advice someone other than the physician provider.

ALL phone conversations should be documented and placed in chronological order within the medical record.

Counter Signatures

A signature is a signature from a doctor review the record by the primary doctor has signed it. The rating implies that the doctor understands and agrees with the care described by the dictating physician.

It is important to recognize that when a provider signs the entry in medical records, they are responsible for whatever is contained in the entry.


Although abbreviations save time, many are unclear and misinterpreted by other doctors. Only standard abbreviations should be used to avoid misinterpretation.

Sources and suspension of physician / patient relationship

ALL issues of patient non-compliance should be objectively documented in the medical record. Action taken, reinforcement or education, should also be noted.

When the doctor intends to inform the patient is told that they should say verbally. A certified letter should then be sent to the patient outlining the reasons for the termination and duration of the relationship will terminate. A copy of the certified letter should also be kept in the record.

Record Retention

The time that medical records will be kept separate in the statute of limitation regulations and individual state laws.

However, any organization must implement clear policies and procedures for maintenance and keeping medical records.

Release Records

Records may only be issued under the authority of the individual state and federal. law

Organizations must also have clear rules on the release of medical records that should decide

* who may request and receive a copy of the patient’s medical

* authorized to release medical records to any party

* how practice will protect protected health

* how release of records will be monitored and documented

strong trend above greatly avoid responsibility.

Ownership Records

ownership of medical records is a unique situation, both the patient and medical institution have ownership interests. The factory owns the physical record however the patient owns the information within the record.

The record must be within the medical institution, and should ensure that patient information is protected.

Patients are entitled to all the information within their record, although such rights differentiate between states.


When a legal requirement arises, medical documents relied upon to determine the standard of care that was provided. Little or no data on treatment strongly supports the claim negligence

records are exposed :.

– a series of events that led to the injury of the patient and the subsequent claim

– inefficient use of information in the medical record

– poor communication from the doctor or department to another

– illegible entries or orders


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