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Medical Record Keeping for Health Care Providers

Introduction: The Purpose of Medical Records

Medical records serve many purposes. First and foremost, they document the history of examination, diagnosis and treatment of a patient. This information is vital for all providers involved in a patient’s care and for any subsequent new provider who assumes responsibility for the patient. In disciplinary or peer review matters, medical records can justify (or refute) the need for a particular treatment. In reimbursement and utilization disputes, medical records can document what services were rendered and whether they were medically necessary. Medical records are the single most important evidence for the provider whenever a malpractice claim, or other inquiry, arises concerning patient care. In today’s health care environment, which now features multi-specialty care, in ever changing health care networks, and often requires consumers to transfer to different providers, the need for comprehensive, accurate medical records simply cannot be overemphasized.

Part I: Content of Medical Records

In a nutshell, medical records should contain sufficient, legible information to demonstrate clearly why the course of treatment was taken or why an apparently indicated course of treatment was not undertaken. Simply put, the records must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and result of the treatment accurately. At a minimum, the records must include patient histories; subjective complaints; examination results; test results, including x-rays; objective assessments; treatment plans; reports of consultations and hospitalizations; record of drugs prescribed, dispensed, or administered; an account of the actual treatment rendered; and copies of records or other documents obtained from other providers and relied upon by the provider in determining the appropriate treatment for the patient.

In addition, many states require certain patient information, such as billing records or test results, to be part of the patient’s “medical records.” Providers should review their individual state laws to see whether more specific record keeping requirements have been imposed.

The Basics: “SOAP

On a day-to-day basis, most providers follow the “SOAP” format to document a typical patient visit. SOAP – Subjective, Objective, Assessment, Plan – is a useful way to obtain consistent, comprehensive records.

Subjective information is gathered from the patient. Symptoms, complaints, and condition, as reported by the patient, are all noted.

Objective information documents the physical examination of the patient. Generally, a head to toe, all systems check-up is noted, followed by positive and negative findings. It is important to note a lack of response, or negative finding, as well as positive findings. Negative findings often document that the appropriate test, or inquiry, was made and that nothing was found. Negative findings also help the provider arrive at a diagnosis.

Assessment is the provider’s analysis of the information gathered thus far. Here the provider notes what his or her suspicions are, what could be the problem, and what is likely not the problem. If a diagnosis can be made, it is noted. The impressions and conclusion the provider has reached at this stage constitute the assessment.

Plan is simply the provider’s plan of action. If a diagnosis was made, the plan will outline the treatment or other measures needed for the patient. If no diagnosis could be reached, the plan will describe further diagnostic studies or follow up that is necessary. The plan might also include a statement stating why a certain treatment or test, if otherwise indicated, is not going to be pursued

Providers who start with a good patient history and maintain records in accordance with the SOAP method are well on their way to avoiding any allegations of insufficient record keeping. While other patient information must also be maintained, the SOAP method assures consistency and, usually, minimally adequate documentation.

The Basics: “SOAP

On a day-to-day basis, most providers follow the “SOAP” format to document a typical patient visit. SOAP – Subjective, Objective, Assessment, Plan – is a useful way to obtain consistent, comprehensive records.

Subjective information is gathered from the patient. Symptoms, complaints, and condition, as reported by the patient, are all noted.

Objective information documents the physical examination of the patient. Generally, a head to toe, all systems check-up is noted, followed by positive and negative findings. It is important to note a lack of response, or negative finding, as well as positive findings. Negative findings often document that the appropriate test, or inquiry, was made and that nothing was found. Negative findings also help the provider arrive at a diagnosis.

Assessment is the provider’s analysis of the information gathered thus far. Here the provider notes what his or her suspicions are, what could be the problem, and what is likely not the problem. If a diagnosis can be made, it is noted. The impressions and conclusion the provider has reached at this stage constitute the assessment.

Plan is simply the provider’s plan of action. If a diagnosis was made, the plan will outline the treatment or other measures needed for the patient. If no diagnosis could be reached, the plan will describe further diagnostic studies or follow up that is necessary. The plan might also include a statement stating why a certain treatment or test, if otherwise indicated, is not going to be pursued

Providers who start with a good patient history and maintain records in accordance with the SOAP method are well on their way to avoiding any allegations of insufficient record keeping. While other patient information must also be maintained, the SOAP method assures consistency and, usually, minimally adequate documentation.

Beyond the Basics: Risk Management

Providers must also be aware at all times that their records could be their “best friend” or “worst enemy” in any malpractice claim made against them. Consequently, efforts should be made to record all details of patient care and interaction which could help the provider explain a patient’s case to an inquiring attorney, court, or jury. These might include some items not automatically considered significant.

Patient contact Efforts to contact a patient by telephone or in writing should be noted, whether successful or not. This is particularly important if the patient has first contacted the provider. Similarly, if a patient repeatedly cancels necessary appointments, efforts made to reschedule the patient should be noted in the chart.

Presence of others The presence of other people with the patient and the provider should often be noted. For example, when a female patient is undergoing a pelvic examination or other exam for which a provider routinely has a staff member present, the name of the staff person should be noted. When extensive treatment options are being explained to a patient and a staff member or other family member is present, the names of those present should be noted.

Consent The patient’s consent for medical treatment and procedures should be obtained by the provider prior to undertaking any treatment or other procedures. This is routinely done through a signed, general statement on the patient history form completed by the patient. For more particular procedures, such as surgery, additional written and informed consent should be obtained. Many states specify the information which must be given to the patient to obtain informed consent. Providers should familiarize themselves with these requirements.

Typically, though, to obtain informed consent, the patient must be advised of the nature of the treatment or procedure, potential significant risks of the treatment or procedure, normal sequelae of each, alternatives to the treatment or procedure, and the consequences of foregoing such treatment or procedure.

Specific informed consent, when necessary, should be obtained on a separate, signed form. The information necessary can be listed on the form, reviewed with the patient and provider, and signed and dated by the patient. The provider should initial or sign the form to indicate the information on the form has been fully discussed. If a staff member is present during the discussion, he or she should also sign or initial the consent form.

Patients who act “AMA” Patients often refuse recommended treatment or diagnostic procedures despite having been told of potential adverse consequences for doing so. This should be noted in the record and, if possible, the patient should sign the entry which indicates what advice has been given and that the patient has chosen to forego the recommended plan of action.

Potential complications Potential complications of a course of treatment should be noted in the record. The failure to recognize or a consider a potential complication, and prevent injury, is a common basis for a malpractice claim. These claims can be defended if the records clearly demonstrate the complication was considered and preventive action taken or, for noted reasons, rejected.

The Feds and Other Payors

The federal government is tremendously involved in the health care industry. As a major payor of health care costs, the government dictates many facets of provider care, including creation and maintenance of medical records. Likewise, health maintenance organizations and other private payors impose special requirements on participating providers.

The Federal Government Many federal programs require certain data in medical records. Providers who participate in Medicaid or Medicare must review the provider manuals for those programs to determine what additional information may be required in patient records. Although not part of the individual patient records, physicians who purchase controlled substances for an office inventory must maintain an inventory and separate log of all controlled substances dispensed. The federal Drug Enforcement Agency can fully advise providers of their obligations.

HMOS and Other Insurers Many HMO’s, insurance companies and other provider networks often impose separate record keeping requirements on participating providers. Although not legal obligations, compliance with these requirements can help providers avoid exclusion fromsuch entities.

Part II: Creating and Maintaining the Records

The Essentials

Most medical records are still largely handwritten. All entries must be legible and should be signed or initialed by the person making the entry. Staff members who have a reason to enter information can do so. This can include office personnel who enter information regarding telephone calls to a patient as well as physicians and other medical staff. All entries should be made in permanent ink; do not use pencil.

All entries should be made as contemporaneously as possible with the event giving rise to the entry, and should be dated on the day they were made. Addendums can be made to a record so long as they are dated on the day they were entered, rather than the date to which they refer. Abbreviations may be used. They should be formally adopted and standardized. A key should be placed in the chart if many abbreviations are used or if unique abbreviations are used.

Many providers dictate notes of their patient encounters. These are then transcribed and entered into the record. The provider should review the note and indicate by initialing or other sign that he or she has reviewed the entry. Any corrections should be made and dated by the person who dictated the entry.

NEVER attempt to remove, alter, or substitute information in medical records. If a correction is necessary, it is best to strike through the incorrect information and add the correct. Any such correction must be dated and signed. The alteration of medical records is a serious offense which can generate a disciplinary action and, in some states, criminal charges.

Computerized Records

The computer age has come to medical record keeping. In addition to billing records, providers may now purchase software programs that create and maintain substantive patient medical records. While these records have some obvious advantages over bulky paper records, the new “paperless” records are far from perfect and warrant special considerations.

Security The primary concern of any provider who considers computerized records must be security. Software used must protect against unauthorized access or alteration of the record, and unauthorized duplication. The system must assure authenticity so that any entry attributed to a certain individual was actually made by that person. The system must insure accurate, and unalterable, dates and times for all entries or inquiries. Many software systems require passwords, security codes or key cards, and even fingerprints to assure proper access. Others include alarms that crash a system and sound off if an unsuccessful attempt is made to access a record. Many contain internal tracking systems to trace every entry and inquiry by individual.

In 1992, the Computer Based Patient Record Institute (CPRI) was formed by a coalition of health care organizations to promote and develop standards for the use of computerized record systems. This group is actively working on the problems that arise from the use of computerized systems so that the many benefits of the paperless record will not be lost.

Records Retention: How long is long enough?

Providers often wonder how long they must retain medical records. Prime factors to consider in determining this are any legal requirements imposed on the providers and the uses to which the records may be put. Often the legal requirement for retention may not be too onerous, but a provider may want to keep the records longer to serve other purposes. There is also no requirement that records be purged or destroyed. If storage space and means permit, providers may choose to maintain all patient records accumulated throughout their careers.

Legal requirements Many state regulatory boards have set minimum time periods. These vary from board to board. Florida, for example, requires physicians to maintain records for five years from the date of last patient contact. Likewise, federal programs, such as Medicare and Medicaid, require records be kept at least 5 years from the date of the last patient contact. HMOs or other health care networks may require participating providers to maintain records for a certain period of time. Providers should review their state regulatory board’s requirements, and review any provider contracts they have to discover any legal obligation placed on them as a participating provider. When a physician or other provider closes or relocates his or her practice, the provider should review any special state provisions governing any required notice to patients and handling of the medical records.

Malpractice suits Providers often wish to maintain records until such time as the statute of limitation (time period) for filing a lawsuit has passed. Again, this can vary from state to state. In addition, there is often a “statute of repose” which sets an absolute outer limit on the time period within which a lawsuit can be filed. For example, a statute of limitation might require a suit to be filed within four years but extend that in case the malpractice was fraudulently concealed. The statute of repose would then limit that period to a maximum of seven years. Consequently, even though a provider might believe he or she should keep the records for only four years, a better course would be to keep them until the maximum time period set by the statute of repose. Providers should contact their professional liability carriers to learn the specific statute of limitation and statute of repose periods in their states.

Finally, providers need to be aware that some states have authorized special statute of limitation periods to allow minors to sue for abuse, once they become adults, or other injuries that do not appear until several years after the malpractice incident. Psychiatrists and providers who routinely treat infants and minors should determine whether they are subject to any of these special statutes of limitation. If so, providers should retain their medical records longer so they can defend a malpractice claim that may not be made until several years after treatment was rendered.

Other purposes Some providers may need patient records for tax purposes to document billing, services rendered, and monies received. If so, to protect themselves in a tax audit, providers may want to keep the records for the length of time recommended by their accountant or financial advisor, even if this is longer than the statute of limitations.

Part III: Confidentiality of Medical Records

An ethical and moral duty to maintain the confidentiality of patient medical information extends as far back as the physician’s Hippocratic Oath—“Whatever, in connection with my professional practice,..I see or hear..,I will not divulge.” Common law, too, provides such a duty as an implied condition in the contract between a physician and patient; the physician warrants that information gained during the relationship will not be released without the patients permission. Various legal bases for confidentiality have also arisen.

State Statutes

Most state laws provide for confidentiality of medical records and place limitations on their release. Some statutes accomplish this by creating a patient-physician privilege which protects information gained through that relationship. Often, too, there is an additional privilege afforded records of psychiatric treatment which prevents their release except under certain, limited circumstances. Providers should become and remain familiar with the particular requirements of their state laws.

Federal Statutes

Many federal statutes provide for confidentiality of patient medical information. The Alcohol and Drug Abuse Act places severe restrictions on the provider’s ability to release information concerning treatment for alcohol or drug abuse. Federal law requires participating Medicare providers to maintain the confidentiality of patient medical information, limit access only to authorized personnel, and generally not otherwise release the records other than to the patient without a subpoena. Even the Freedom of Information Act, which provides for the fullest possible disclosure, does not apply to medical and personnel records, as this would be an unacceptable invasion of personal privacy.

Superconfidential Records

The HIV/AIDS epidemic has created a new category of medical records—the Superconfidential record. In 1988, Florida became one of the first states to enact broad, sweeping legislation to govern the compilation and release of HIV/AIDS related information. Many other states have followed suit and providers should review their particular states’ requirements. Simply put, most laws on this issue require absolute confidentiality of HIV test results and impose special requirements which must be met before such information can be released. The states’ initiative on this issue has been as a result of federal legislation (The Ryan White Care Act) which directed the states to enact legislation, in part, to guard against unauthorized release of, or access to, superconfidential HIV information.

Part IV: Access to Medical Records—The Flip Side of Confidentiality

Generally, medical records cannot be released without a signed authorization by the patient or the patient’s legal representative. A valid authorization should be signed and dated within proximity of the request. The authorization should identify the patient and specify the information that should be released. The authorization should be addressed to the provider or institution that has the records and should clearly state to whom or what entity the records are to be provided. The authorization should be witnessed. If a provider has any question about the validity of an authorization for release of medical information, he or she should seek legal advice before releasing any information.

Records can also be requested through subpoena. Usually an authorization will accompany the subpoena. In some instances, this may not be required. A provider should seek legal advice to resolve any question about the appropriate response to a subpoena.

Special Considerations

Mental Health Records There is a general, overriding principle that records of mental health treatment are confidential and should not be released. The policy for this privilege is to encourage people to seek treatment for mental disorders. Typical state laws, which are modeled after federal legislation which governs federally funded programs, prohibit release of mental health treatment records or information except pursuant to the express, written and informed authorization of the patient or patient’s legal representative. The release must specify that mental health treatment records are being released and name the person or entity to whom the records are being released; a general release will not suffice. A valid court order may also permit release; likewise, information can usually be released to a provider directly involved in patient care. There are exceptions to the confidentiality provisions, such as with “duty to warn” provisions. These vary largely from state to state; providers should familiarize themselves with particular laws applicable to them. Information can often be released (without identifying information) to abuse registries and for purposes of scientific research.

Substance Abuse Records As with mental illness, public policy supports those individuals who seek treatment for substance abuse problems by affording special confidentiality privileges to the records of such treatment. Federal law, applying to federally funded programs, proscribes many of these requirements but state laws have also followed suit. The special consideration given to substance abuse records is similar to records of mental health treatment. The records may only be released upon a valid, specific authorization for release of information which specifies the records to be released and to whom they are to be provided. Most such records, if released, carry a notice that details the confidentiality of the records, limitations on their use, and penalties for violations of such requirements. A valid court order can also permit disclosure of substance abuse treatment records. Providers should take special care to insure their ability to release this information; any doubts about this ability should be resolved through legal advice.

Superconfidential Records The typical special handling requirements afforded HIV test results include:

1. A legally effective release that specifies an HIV test result is to be released to a named third party, rather than a general release;

2. A court order for records sought by subpoena; the subpoena, in this instance, is insufficient;

3. A verbal and written warning statement to the recipient of the HIV test result that the information is superconfidential;

4. “Need to know” situations which permit disclosure of HIV test results to agents and employees within health care provider or facility who have a need to know the information in order to perform their job duties; these disclosures do not need to be accompanied by the warning that the information is superconfidential.

The requirements discussed here for the disclosure of superconfidential medical information are typical requirements among the states that have enacted such requirements. Providers should be aware of the potential for these special requirements and take appropriate action to learn and implement any requirements applicable to them.

Part V: Pitfalls to Avoid

In light of all that has been said thus far in this course, it is important to highlight a few key pitfalls to avoid. Since the medical records can sometimes “make or break” a provider’s defense or claim, extreme care should be taken to maintain adequate patient records.

Omitting Required Information

If a provider’s state regulations require certain items in the medical record, they should be there. Failing to include required information leaves a provider vulnerable to disciplinary action and claims of negligence for inadequate record keeping.

Using Bad Language

Records should be professional and not contain disparaging remarks about the patient, the patient’s relatives, or other medical providers. Only accurate, pertinent information should be recorded. If the conduct or words of the patient, patient’s relatives, or another provider are relevant to what transpires with the patient, the information should be noted, but only to recount some aspect of the patient’s course of treatment. Remarks made to “vent” serve no purpose for the provider.

Illegible Records

A provider’s records will serve no purpose if they cannot be read. Due care should be taken to ensure accurate, legible information is recorded in the records. Providers should maintain their records so that they are capable of being reviewed and understood by another person without any special care or translation.

Too Many Abbreviations

A provider is not well served by records with so many abbreviations that a key must be referred to constantly to “decipher” the records. Excessive abbreviations can also make the provider appear hurried and impersonal. This would not bode well in the defense of a malpractice suit.

Errors

While mistakes can be made and should be corrected through the strike out method, excessive errors give the appearance of negligence or carelessness. However, claims that an entry in a record contains an error have no credibility; whatever is in the record is deemed correct unless appropriately noted. So, if you make an error, correct and date your correction. Just try to insure accuracy the first time around so that errors and corrections are kept to a minimum.

Omitting Relevant Information

Finally, providers should remember a fundamental rule of medical record keeping. “IF IT ISN’T IN THE RECORD, IT DID NOT HAPPEN.” If a provider fails to note a test, a pertinent conversation with the patient, a consultation with another provider, or similar useful information, it is presumed the event never occurred. The provider has an extremely uphill battle to demonstrate anything occurred in the case, other than what was noted in the record. Consequently, it is generally better to err on the side of including too much information rather than too little in the medical record.


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