A medical record is more than just a collection of facts that helps guide the care delivered to a patient. Because it's a historical and legal document that provides an account of each encounter between a provider and the patient, it's vital that they are both accurate and thoroughly complete. The following four standards of patient medical records documentation provide a framework for providers:
1. Structure of the Medical Record
Not only must all patient records be organized, but they also must be consistent in their structure. Entries must be in chronological order to facilitate ease of retrieval of the facts. A patient's record must contain only information regarding that particular patient and no one else. Each page of the patient's medical record must include either their name or their identification number.
All entries in the patient's record must be dated, legible and as complete as possible. The format that the information is presented in must be easily understood by someone other than the person inputting it without requiring them to use a separate key or legend.
The accurate documentation of the patient's personal data including their name, address, phone number, marital or partnership status and employer is vital. If the patient self-reports items such as ethnicity, preferred language and race, these must also be noted.
The author of the notes must clearly and accurately noted with their professional credentials included. In this case, stamps are not acceptable, though initials may be used as long as the credentials are also included.
2. Thorough Medical History
The medical history standard places significant emphasis on thoroughness. It should include an accurate list of any medical problems the patient is currently being treated for or was in the past. Some examples of elements that must be included are chronic medical conditions, significant behavioral health issues, past medical history and surgical conditions. For patients under the age of 18, information about their birth, prenatal care and childhood diseases and surgeries should be documented.
An accurate medication list must also be present in the patient's medical history. Some information that should be included is the name of the medication, the condition it's treating, the dosage and frequency. Any supplements, over-the-counter medications and herbal treatments should also be noted here.
If the patient has ever had an adverse reaction to a substance or medication, it should be documented in their medical history. Allergies must be also be noted here as well as if the patient has no known allergies, if applicable.
Continuity and coordination of care must be noted. This includes all services and testing that has been ordered, all referrals, any therapeutic services and diagnostic services.
Advance directive information must be obtained and noted for all patients aged 18 years and older. This is a requirement of the Centers for Medicare and Medicaid Services (CMS).
3. Summary of Medical Care
The summary of medical care is composed of three primary elements: purpose of the visit, proposed diagnosis and preventive screenings. When applicable, the provider should use the subjective, objective, assessment and plan (SOAP) format when taking notes about the patient's reason for visiting the office.
The proposed diagnosis must take into consideration any past and present conditions of the patient. When documenting the patient's progress, any treatment changes and additional diagnosis(es) must be updated accurately. Preventative screenings must reflect age-appropriate practices and follow the guidelines established for such care.
4. Guarding Patient Privacy
Maintaining the safe confidentiality of each patient's record starts with storing them in a secure area that is not accessible by the public. In addition, the office staff must be retrained periodically to reinforce confidentiality procedures.
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