Contents Legal system Malpractice Avoiding malpractice Medical record Introduction Proper documentation Subjective vs objective Legal considerations Managing records Record storage Releasing records Viewing records Withholding records Selling records FAQs Patients' rights QUIZ

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.