Irregularities in the medical record emerge during a medical chart review. Physicians must be careful when preparing the medical chart.

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Medical Record Documentation Guidelines
to Avoid Legal Risks
Irregularities in the medical record emerge during a medical chart review.
Physicians must be careful when preparing the medical chart.
Documentation in the medical record is of immense significance in the legal system
and the failure to document pertinent information is regarded as a major breach
and a deviation from the accepted standard of care. Missing medical details,
erratic data and so on are identified during medical chart reviews performed for
legal purposes. Wrong information as well as missing information could result in
negative patient outcomes including injury or even death. Proper documentation
can help avoid negative legal repercussions. Legal risks are not the only reason
that necessitates accurate medical chart documentation. The medical record
represents the entire medical history of the person, and is very significant from
the point of view of ongoing care, research, and quality assurance. Therefore, the

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medical record of a patient must be complete, error-free, confidential, timely,
and appropriate.
When preparing the medical chart, it is important to consider who all are likely to
access and read the record. These would include members of the care team,
physicians on call, ER physicians, medical peer review physicians, insurers,
attorneys, and quality assurance reviewers. With the introduction of the EHR, and
the trend of encouraging patient participation in their care, patients also may be
viewing their medical record. By keeping the possible audience in mind when
creating the record, physicians can ensure clarity and an easily understandable
style of communication, which are vital as regards liability prevention as well as
optimum patient care.
The NCQA (National Committee for Quality Assurance) has outlined a set of
commonly accepted standards for medical record documentation. Among these six
are to be considered core components:
1. Significant illnesses and medical conditions must be indicated on the
problem list.
2. Medication allergies and adverse reactions must be clearly noted in the
medical record. If the patient has no known allergies or history of adverse
reactions, this must be properly noted in the record.
3. For patients seen three or more times, their past medical history must be
easily identified and include 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.
4. Working diagnoses must be consistent with findings.
5. Treatment plans must be consistent with diagnoses.
6. There should be no evidence that the patient is placed at inappropriate risk
by a diagnostic or therapeutic procedure.
Apart from these 6 core components, there are other elements required for
consistent, current and complete documentation. The patient’s name or ID number
must be included on each page, and personal biographical data must include the
address, employer, home and work telephone numbers and marital status. Ideally,
all entries in the record must be dated, and contain the author’s identification in

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the form of a handwritten signature, initials or unique electronic identifier. The
medical record must be intelligible to someone other than the writer. Any
applicable subjective and objective information pertinent to the patient’s
presenting complaints must be identified in the history and physical examination.
The medical record should also show that laboratory and other studies ordered are
appropriate.
Patient encounter forms and notes should record follow-up care, visits or calls (in
months or weeks) when indicated. Also, the medical chart should show that any
unresolved problems from earlier office visits are addressed in the follow-up visits.
In case a consultation is requested, there should be a note from the consultant
included in the medical record. The practitioner who ordered consultation, lab
tests, or imaging tests must initial the respective reports filed in the chart.
All the above elements are relevant from a legal perspective, and may be focused
on during a medical record review performed for medical malpractice litigation,
or other investigative evaluations. The attorneys defending the accused physician
can make their inferences only from the documentation provided in the medical
chart. This brings home the importance of sensible charting techniques, and why
clinicians must focus more on appropriate medical charting. Proper documentation
reduces the chance of malpractice lawsuits and risk to the patient.