Medical Record-Keeping

The Doctors Company, a medical malpractice insurer, has published this article about keeping medical records. 

An excerpt:

The following entries should appear in the office or hospital records of each patient:

  • Results of a patient’s physical examination, specifically noting the absence of abnormality.
  • Patient history, a list of all medications with particular emphasis on current medications, to include over-the-counter drugs and supplements and any allergies or drug sensitivities.
  • Specific notation on the patient’s experience, if any, with drug or alcohol abuse and family or emotional problems.
  • Progress notes, entered after each office visit, about any change in status. (If negative, your follow-up should be indicated.)
  • Signed and witnessed consent forms for special procedures or surgery.
  • Patient response to medication or procedures.
  • Patient failure to follow advice or to keep appointments and any refusal to cooperate. (Log missed appointments and follow-up telephone calls and letters.)
  • All significant laboratory or x-ray reports and the dates when they were ordered and read.
  • Copies or records of instructions of any kind (including diet) and directions given to the family.
  • Records of consultations with other physicians and their written or oral responses, with the dates and times.
  • Thorough documentation of any patient’s grievance, including the date and time.