Proper Patient Records
As a medical professional, your notes and patient records are critical to both protecting you and providing the best patient care you can. Keeping detailed patient records is critical to protecting you in the case of any malpractice case.
My name is Sara Schroeder and I am here to provide you with some helpful tips on how to keep good patient records.
Lets start with a detailed history
A detailed history is one important part of a patient’s records. Having the patient complete a thorough patient history will give you information that will help you to provide proper care to the patient.
The history should give you the reason for the visit, including what complaints the patient presented with, and any unusual events, such as trauma, that may have occurred prior to the patient coming for treatment.
The patient should also provide a list of all current medications they have been prescribed, which ones they are actually taking, and any allergies they may have.
Always pay special attention to anything in their history that may indicate contraindications for treatment and suggest a referral if and when necessary.
Make sure to have your patients sign an informed consent form. For a more thorough discussion of informed consent, watch the video on this site dedicated to just that topic.
Now lets talk about the Examination.
The examination is also a critical part of the patient’s record. Make sure to document all clinical findings, both positive and negative.
By documenting negative findings as well, your records will reflect how thorough your examination was. If it is necessary to take x-rays, make sure that those are also part of the patient’s chart.
If a case is brought against you, a jury will want to know what symptoms the patient presented with and whether it was appropriate for you to provide treatment to that patient.By getting a detailed history and performing a thorough examination, your notes can provide critical evidence that your care was appropriate.
Make sure to document the patient’s diagnosis and treatment plan, the type of treatment and rationale as well as any treatment alternatives that were rejected and why.By carefully detailing what treatment you provided, your notes can be critical in protecting you from any malpractice claim. If you use any abbreviations, maintain a legend for those abbreviations.
Any instructions and patient education materials that you give your patient, should be documented in the patient’s chart. Maintain copies of any referral letters and prescriptions.
Make sure to keep the patient information current. Have patients complete updated histories when needed. Also make sure to document any re-examinations.
Always sign the patient’s record, and keep financial and clinical information separate in the chart.
If you use Electronic Records, which are becoming increasingly common practices, make sure that you are aware of what information carries over from one visit to the next. You do not want cookie cutter records that are identical across numerous visits. You want to make sure that each record reflects the symptoms that the patient presented with on that particular visit and the treatment that was received.
If a patient requests records, make sure that a valid Release of Records Authorization form is signed by the patient and then keep it in the patient’s chart.
It is your duty to maintain patient records that a subsequent treater is able to understand what care was provided and why.
Make sure that you are aware of the federal and state regulations for how long patient records must be maintained. If you close your practice or move offices, this does not end your duty to maintain the patient records.
I’m Sara Schroeder and remember, by maintaining good patient records, you can provide your patients with excellent care and also protect your practice.