Handbook Contents Introduction Risk management Insurance program Legal system Medical records Incident reporting Physician-patient Informed consent Infectious disease Confidentiality Patient's rights Risk Home Page

What to Avoid in the Medical Record Avoid the use of words that subjectively categorize a patient's treatment or condition, such as unintentionally, inadvertently, unexplainably, accidentally and unfortunately. Do not leave loose ends in the chart. Follow-up on diagnostic tests ordered with results not yet received, and/or abnormal test results. The medical record should never be used as a forum for remarks to "cover" yourself. Never make statements in the record which criticize or cast blame upon others, or are intended to serve as gratuitous remarks. Do not engage in battles in the chart over treatment decisions. When disagreements regarding a patient's treatment plan occur, a case conference should be called to resolve them. This advice, however, is not intended to preclude using the medical record to list differential diagnoses and the process of excluding potential diagnoses. Documentation of Incidents and Unanticipated Patient Outcomes Incidents and unanticipated patient outcomes should be promptly, clearly and objectively documented in the medical record. Because these occurrences may form a basis for litigation even when there has been no negligence, the best defense is a record which contains timely, accurate and properly charted information. Assign a member of the treatment team with first-hand knowledge of the event to record the event. Entries regarding an incident should include the date and time of the incident, a brief factual and objective description of what was seen and heard, using exact quotes when possible of the patient's description of the event, along with the findings of any physical examination and follow-up care. When there is no apparent injury as a result of the incident, this should be clearly documented in the record. Avoid writing information unrelated to the medical care of the patient. The record should not make reference to the preparation of an incident report and/or notification of the hospital's Office of Legal Affairs. When unanticipated patient outcomes occur, documentation of the complication(s) should also be accurately recorded. Entries should include information regarding the complication in an objective fashion without judgment as to whether the complication is acceptable, unacceptable or anyone is to blame. The entry should indicate that the patient was informed of the complication and its consequences, as well as any change in his or her treatment plan, should it be necessary.   Frequently Asked Questions About Medical Records Question: How should a physician respond to a letter from a patient's attorney requesting medical information? Answer: Be sure the request contains an original dated written authorization from the patient, or the parent or guardian of a child, or when the patient is deceased, the appropriate legal representative of the patient's estate. If the release is more than one year old, it is prudent to request a more recent one. Forward a complete copy of the patient's record, or only specifically requested items if they have been detailed. You may request a reasonable fee for photocopies and processing the request; by statute in Connecticut a hospital may charge 65cents per page plus 1st class postage; a physician's office may charge 45cents plus postage. You should not prepare a written summary of the patient's care and treatment. Because specific laws and regulations impose liability and monetary penalties for the unauthorized disclosure of patient information regarding HIV status, alcohol or drug treatment and psychiatric treatment, without specific written authorization from the patient, a release form for this information must explicitly authorize its release. It is strongly recommended that you notify the Office of Legal Affairs of any record request by an attorney or dissatisfied patient so that individual consultation and advice regarding the request can be provided. Question: What do I do if I disagree with a note that someone wrote in the chart? Answer: It is not uncommon for members of the health care team to disagree occasionally among themselves or with a consultant's recommendations. Usually, these disagreements can be resolved by discussing them at case conferences and do not need to be documented in the record. However, when a health care provider believes the patient's care is affected, the disagreement should be discreetly, factually and objectively documented, always expressing a tone of concern for the patient's well-being, rather than hostility among the members of the team. Example: Dr. Doe's recommendation that the patient be started on Streptomycin is noted. Due to the patient's prior history of being sensitive to this medication, the patient will be continued on his current antibiotic regimen and will be followed with daily blood cultures. Question: How long must I retain a medical record on a patient whom I have not seen in sometime? Answer: In Connecticut, a hospital must retain a patient record for at least 25 years. Licensed health care providers must retain office records for 7 years from the date of last treatment or 3 years from the death of the patient. Question: Who owns the medical record? Answer: The health care provider or facility that created the records owns the original. A patient is entitled to a copy of the record but not the original. Question: What do I do if a patient demands to see his or her record while he or she is hospitalized, before it is complete, or in the office? Answer: Generally the patient has the right to a copy of the hospital record after the patient is discharged and after it is completed (e.g., operative notes and discharge summary dictated and signed). However, there may be times when, to defuse a situation, you may decide to let the patient read the original. When this occurs, a staff member must be present to maintain the integrity of the record, prevent the patient from adding comments or crossing out notes, and possibly to answer questions about the notes.