What Information Must a Doctor Include in a Patient’s Medical Records?
Medical record contents are governed by standard practice and federal rules, starting with CMS Conditions of Participation. Records must include the following information to ensure comprehensive documentation and support patient care:
Information to Justify Admission and Continued Hospitalization:
Notes
Documentation
Records
Reports
Recordings
Test results
Assessments
Support for Diagnosis:
Detailed documentation to support the diagnosis
Patient Progress and Response:
Description of the patient’s progress
Response to medications
Response to services such as interventions, care, treatments, etc.
Complete Information/Documentation:
Evaluations
Interventions
Care provided
Services provided
Note: The inclusion of medical errors or failures in the actual patient record, as opposed to some internal and protected file, is still a matter of debate.
Specialized practices, such as oncology with radiation orders, have their own set of rules.
Legal Provisions:
CMS Conditions of Participation (CoPS):
All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service, consistent with hospital policies and procedures.
HHS Guidelines:
Hospitals using electronic medical records must demonstrate how they prevent alterations of record entries after they have been authenticated. Information needed to review an electronic medical record, including pertinent codes and security features, must be readily available to surveyors for review.
When state law and/or hospital policy requires that entries in the medical record made by residents or non-physicians be countersigned by supervisory or attending medical staff members, the medical staff rules and regulations must address counter-signature requirements and processes.
A system of auto-authentication in which a physician or other practitioner authenticates an entry that they cannot review (e.g., because it has not yet been transcribed, or the electronic entry cannot be displayed) is not consistent with these requirements.
Importance in Medical/Legal Context:
In medical malpractice cases, altered or incomplete records can be seen as a silent confession of guilt by a jury.
The Medical Board of California often alleges poor record keeping as an adjunct to license challenges based on negligence or gross negligence.
Recommendations:
Office procedures and systems should be reviewed by large, experienced outside entities, even if these entities are not "the best" in their field. In terms of record keeping, patient files, HIPAA, and other practice structure issues, being part of the mainstream is more important than being the best.