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Medical Record Documentation The medical record serves many purposes but its primary function is to plan for patient care and provide for continuity in information about the patient's medical treatment. As a permanent record, the patient's medical record informs other health care providers both inside and outside the hospital about the medical history of the patient. In addition, the medical record: provides information which serves as the basis for financial reimbursement to hospitals, health care providers and patients; serves as a legal document for use by an injured patient against other parties or for use in other legal proceedings; is used by hospital quality assurance and peer review committees, State licensing agencies, State regulatory agencies, and other entities in accessing the quality of patient care by hospitals and health care providers; is a key portion of accreditation processes such as that of the JCAHO. From the risk management perspective, the medical record is a crucial element in preventing and minimizing the potential adverse consequences of malpractice litigation. Ultimately, it serves as the basis for the defense of malpractice claims and lawsuits. Medical records which are poorly maintained, incomplete, inaccurate, illegible or altered, create questions of fact regarding the treatment given to a patient. Patient's attorneys often institute malpractice lawsuits when they believe the questions of fact created by incomplete and poorly documented medical records will cause a jury to find liability against a hospital and/or health care provider. Proper documentation in the medical record creates a legal document which accurately and completely reflects the care provided to a patient and, in a courtroom setting, it may be likened to a witness whose memory is never lost. It serves to correlate, for all involved, important patient information regarding the treatment rendered and the patient's treatment plan, and is the means by which a level of communication is achieved among all health care providers involved in the patient's care.   Proper Documentation of the Medical Record Each and every page of a patient record should be clearly labeled with the patient's complete name and medical record number. Individuals making entries in a patient's chart should do so only through a password electronic system, or on hospital approved medical record forms and then only with pen rather than pencil, which might fade and become illegible, or felt tips which might bleed through the page. Include the complete date of the entry with the month, day, year and time of day. Use only hospital accepted medical abbreviations and terminology. Associated records and tests such as EKG's, EEG's, fetal monitoring tracings, etc., should all be properly labeled with patient's name and medical record number, and when appropriate, the date and time performed. All entries in the medical record should be dated, include an indication of the time the note was written and be signed by the person making the entries. Attending physicians may be required to review and countersign progress notes by interns and residents. Progress notes by junior residents should include reference to the fact that a specific aspect of the patient's condition or treatment plan was discussed with a senior resident or attending physician. All examinations of the patient should be documented in the record. Progress notes should indicate that the patient was kept informed of his or her condition, as well as the treatment plan. Document all instances of patient non-compliance or refusal of recommended treatment and that the patient was informed of potential consequences. Patient records should never be altered. One should not erase, obliterate or attempt to edit notes previously written. All corrections, late entries, entries made out of time sequence, and addenda should be clearly marked as such in the record, and should be dated and timed on the day they are written and signed. Draw a single line through any erroneous chart entry and write "error" with the date and time, as well as your initials. Health care providers should only document factual and objective information from their own treatment and/or observation of the patient. When documenting information derived from other sources, for example, other health care providers, other medical records, or entries in the same medical record, be sure to reference the source of that information. Subjective documentation is far less clinically useful than objective information. Examples of objective/subjective charting include: Objective statements Subjective statements Half of breakfast eaten Diet taken fairly No complaints of pain Had a good day Surgical incision healing- no signs of infection Wound OK Thrashing in bed Appears restless IV site clear and infusing at 40 drops per minute IV running well A means by which health care providers can document factual and relevant information is by specifically charting information based upon what is: Seen - charting observations regarding bleeding, deformities, drainage, color of urine, patient posture and/or attitude; Heard - the patient's complaints/statements, moaning, breathing abnormalities, bowel sounds; Smelled - malodorous drainage, alcohol or acetone on breath, fecal or vomitus odor; Felt - areas of induration, hot, cold, dry or moist skin, motion at a fracture site. When a patient is discharged, it is good medical practice to write a final note commenting on the stability of the patient by noting the patient's vital signs, the status of recovery from the condition on admission, or for an elective admission, the status of recovery from the elective treatment/surgery. The note should completely document the discharge instructions given to the patient and/or the patient's family members. Following a patient's discharge, health care providers should promptly complete the medical record in accordance with hospital requirements to enable the medical record department to secure the patient record expeditiously and safely.