As a healthcare professional, you know proper medical documentation is important for many reasons. With precise information, each health care professional to treat a patient can review the correct information at various stages of treatment and provide the best care.
Detailed information is also extremely important in the case of a malpractice lawsuit against members of the health care team. Comprehensive, professional and accurate patient records is one of the best defenses against a malpractice suit.
The following list from the National Committee for Quality Assurance (NCQA) reflects a set of commonly accepted standards for medical record documentation. Make sure your documentation always has these requirements:
- Each page in the record contains the patient’s name or ID number.
- Personal biographical data includes the patient’s address, employer, home and work telephone numbers and marital status.
- All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials.
- All entries are dated.
- The record is legible to someone other than the writer.
- Significant illnesses and medical conditions are indicated on the problem list.
- Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
- Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
- For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances (for patients seen three or more times, query substance abuse history).
- The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s complaints.
- Laboratory and other studies are ordered, as appropriate.
- Working diagnoses are consistent with findings.
- Treatment plans are consistent with diagnoses.
- Encounter forms or notes have a notation regarding follow-up care, calls or visits, when indicated. The specific time of return is noted in weeks, months or as needed.
- Unresolved problems from previous office visits are addressed in subsequent visits.
- There is review for under- or over-utilization of consultants.
- If a consultation is requested, there a note from the consultant in the record.
- Consultation, laboratory and imaging reports filed in the chart are initialed by the practitioner who ordered them, to signify review. (Review and signature by professionals other than the ordering practitioner do not meet this requirement.) If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of follow-up plans.
- There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.
- An immunization record (for children) is up to date or an appropriate history has been made in the medical record (for adults).
- There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines.
Even with proper medical documentation that follows these best-practices, it still important to have Professional Liability Insurance as a medical professional. Professional Liability Insurance will help cover legal fees and the other expenses that you may encounter as a result of claims and litigation brought against you based on the care you provided.
For more tips on maintaining proper medical documentation and Professional Liability Insurance, contact Lockton Affinity.