The medical chart is a confidential document that contains detailed and comprehensive information on the individual patient and their care experience.
The purpose of the medical chart is to serve as both a medical and legal record of patient clinical status, care, history, and caregiver involvement. The detailed information contained in the chart is intended to provide a of the patient's clinical condition by detailing diagnoses, treatments, tests and response to treatment, as well as any other factors that may affect the clinical state of the patient.
The term medical chart or medical record is a general description of a collection of information on a patient. However, different clinical settings and systems utilize different forms of documentation to achieve this purpose. As technology progresses, more institutions are adopting computerized systems that aid in clear documentation, enhanced access, and efficient storage of patient records.
New uses of technology have also raised concerns about confidentiality. Confidentiality, or patient privacy, is an important principle related to the chart. Whatever system may be in place, it is essential that the health care provider protect the patient's privacy by limiting access to authorized individuals only. Generally, physicians and nurses write most frequently in the chart. The documentation by the clinician who is leading treatment decisions (usually the physician) often focuses on diagnosis and prognosis, while the documentation by the nursing team generally focuses on patient responses to treatment and details of day-to-day progress. In many institutions the medical and nursing staff may complete separate forms or areas of the chart specific to their disciplines.
Other on-staff health care professionals that have access to the chart include physician assistants; social workers; psychologists; nutritionists; physical, occupational, speech, or respiratory therapists; and consultants. It is important that the various disciplines view the notes written by other specialties in order to form a complete picture of the patient and provide continuity of care. Quality assurance and regulatory organizations, legal bodies, and insurance companies may also have access to the chart for specific purposes such as documentation, institutional audits, legal proceedings, or verification of information for care reimbursement. It is important to know the institution's policies regarding chart access in order to ensure the privacy of the patient.
The medical record should be stored in a predesignated, secure area and discussed only in appropriate and private clinical areas. The patient has a right to view and obtain copies of his or her own record. Special state statutes may cover especially sensitive information such as psychiatric, communicable disease (i.e., HIV), or substance abuse records. Institutional and government policies govern what is contained in the chart, how it is documented, who has access, and policies for regulating access to the chart and protecting its integrity and confidentiality. In cases where chart contents need to be accessed by individuals outside of the immediate care system, the patient or patient representative is asked for written permission to release records. Patients are often asked to sign these releases so that caregivers in new clinical settings may review their charts.
Documentation in the medical record begins when the patient enters the care system, which may be a specific place such as a hospital or a program such as a home health care service. Frequently the facility will request permission to obtain copies of previous records so that they have complete information on the patient. Although chart systems vary from institution to institution, there are many aspects of the chart that are universal. Frequently used chart sections include:
- Admission paperwork: includes legal paperwork such as living will or health care proxy, consents for admission to the facility or program, demographics, and contact information.
- History and physical: contains comprehensive review of patient's medical history and physical exam.
- Orders: contains medication and treatment orders by the doctor, nurse practitioner, physician assistant, or other qualified health care team members.
- Medication record: records all medication administered.
- Treatment record: documents all treatments received, such as dressing changes or respiratory therapy.
- Procedures: summarizes diagnostic or therapeutic procedures, i.e., colonoscopy or open-heart surgery.
- Tests: provides reports and results of diagnostic evaluations, such as laboratory tests and electrocardiography or radiography images or summaries.
- Progress notes: includes regular notes on the patient's status by the interdisciplinary care team.
- Consultations: contains notes from specialized diagnosticians or care providers.
- Consents: includes permissions signed by patient for procedures, tests, or access to chart. May also contain releases, such as the release signed by the patient when leaving the facility against medical advice (AMA).
- Flow records: tracks specific aspects of patient care that occur on a routine basis, using tables or chart format.
- Care plans: documents treatment goals and plans for future care within the facility or following discharge.
- Discharge: contains final instructions for the patient and reports by the care team before the chart is closed and stored following patient discharge.
- Insurance information: lists health care benefit coverage and insurance provider contact information.
These general categories may be further divided for the individual facility's purposes. For example, a psychiatric facility may use a special section for psychometric testing, or a hospital may provide sections specifically for operations, x-ray reports, or electrocardiograms. In addition, certain details such as allergies or do not resuscitate orders may be displayed prominently (i.e., on large colored stickers or special chart sections) on the chart in order to communicate uniquely important information. It is important for the health care provider to become familiar with the charting systems in place at his or her specific facility or program.
It is important that the information in the chart be clear and concise, so that those utilizing the record can easily access accurate information. The medical chart can also aid in clinical problem solving by tracking the patient's baseline, or status on admission; orders and treatments provided in response to specific problems; and patient responses. Another reason for the standard of clear documentation is the possibility of the legal use of the record, when documentation serves as evidence in exploring and evaluating the patient's care experience. When medical care is being referred to or questioned by the legal system, the chart contents are frequently cited in court. For all of these purposes, certain practices that protect the integrity of the chart and provide essential information are recommended for adding information and maintaining the chart. These practices include:
- Include date and time on all records.
- Include full patient name and other identifiers (i.e., medical record number, date of birth) on all records.
- Mark continued records clearly (i.e., if note continued on reverse of page).
- Sign each page of documentation.
- Use blue or black non-erasable ink on handwritten records.
- Keep records in chronological order.
- Prevent disposal or obliteration of any records.
- Note documentation errors and correct clearly, i.e., by drawing one line through the error and noting presence of error, initialing the area.
- Avoid excess empty space on the page.
- Avoid abbreviations or use only universally accepted abbreviations.
- Avoid other unclear documentation, such as illegible penmanship.
- Avoid including contradictory information. For example, if a nurse documents that a patient has complained of abdominal pain throughout the shift, while the physician documents that the patient is free of pain, these discrepancies should be discussed and clarified.
- Provide objective rather than subjective information. For example, do not allow personality conflicts between staff to enter into the notes. All events involving the patient should be described as objectively as possible, i.e., describe a hostile patient by simply stating the facts, such as what the patient said or did and surrounding circumstances or response of staff, without using derogatory or judgmental language.
- Document any occurrence that might affect the patient. Only documented information is considered credible in court. Undocumented information is considered questionable since there is no written record of its occurrence.
- Always use current date and time with documentation. For example, if adding a note after the fact, it can be labeled "addendum" and inserted in correct chronological order, rather than trying to insert the information on the date of the actual occurrence.
- Record actual statements of patients or other individuals in quotes.
- Never leave the chart in an unprotected environment where unauthorized individuals may read or alter the contents.
Several methods of documentation have arisen in response to the need to accurately summarize the patient experience. In the critical care setting, flow records are often used to track the frequent patient evaluations, checks of equipment, and changes of equipment settings that are required. Flow records also offer the advantages of displaying a large amount of information in a relatively small space and allowing for quick comparison. Flow records can also save time for the busy clinician by allowing completion of checklists versus narrative notes.
Narrative progress notes, while more time consuming, are often the best way to capture specific information about the patient. Some institutions require only charting by exception (CBE), which requires notes for significant or unusual findings only. While this method may decrease repetition and lower required documentation time, most institutions that use CBE notes also require a separate flow record that documents regular contact with the patient. Many facilities or programs require notes at regular intervals even when there no significant occurrence, i.e., every nursing shift. Frequently used formats in patient notes include SOAP (Subjective, Objective, Assessment, Plan) notes. SOAP notes use a subjective patient statement to capture an important aspect of care, then follow with a key objective statement regarding the patient's status, a description of the patient assessment, and a plan for how to address patient problems or concerns. Focus charting and PIE (problem-interventionevaluation) charting use similar systems of notes that begin with a particular focus such as a patient concern or a nursing diagnosis. Nursing diagnoses are often used as guides to nursing care by focusing on individual patient needs and responses to treatment. An example of a nursing diagnosis would be "Fluid volume deficit" for a patient that is dehydrated. The notes would then focus on assessment for dehydration, interventions to address the problem, and a plan for continued care, such as measurement of input and output and intravenous therapy.
Current medical charts are maintained by the health care team and usually require clerical assistance, such as the unit clerk in the hospital setting. No alterations should be made to the record unless they are required to clarify or correct information and are clearly marked as such. After patient discharge, the medical records department of a facility checks for completeness and retains the record. Sometimes the record will be made available in another format, i.e., recording paper charts on microfilm or computer imaging. Institutional and state laws govern storage of charts on-and off-site and length of storage time required.
Health care team roles
All members of the health care team require thorough understanding of the medical chart and documentation guidelines in order to provide thorough care and maintain a clear, concise, and pertinent record. Health care systems often employ methods to guarantee thorough and continuous use and review of charts across disciplines. For example, nursing staff may be required to sign below every new physician order to indicate that this information has been communicated, or internal quality assurance teams may study groups of charts to determine trends in missing or unclear documentation. In legal settings, health care team members may be called upon to interpret or explain chart notations as they relate to the individual legal case.
Thorough training is essential prior to independent use of the medical chart. Whenever possible, the new clinician should spend time reviewing the chart to get a sense of organization and documentation format and style. Training programs for health care professionals often include practice in writing notes or flow charts in mock medical records. Notes by trainees are often initially cosigned by supervisors to ensure accurate and relevant documentation and document appropriate supervision.
Consultationvaluation by an expert or specialist.
Continuityonsistency or coordination of details.
Disciplinen health care, a specific area of preparation or training, i.e., social work, nursing, or nutrition.
Documentationhe process of recording information in the medical chart, or the materials in a medical chart.
Interdisciplinaryonsisting of several interacting disciplines that work together to care for the patient.
Objectiveot biased by personal opinion
Prognosisxpected outcome of an illness or injury.
Regulatory organizationrganization designed to maintain or control quality in health care, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Department of Health (DOH), or the Food and Drug Administration (FDA).
Subjectivenfluenced by personal opinion or experience.
Marrelli, T. M., and Deborah S. Harper. Nursing Documentation Handbook, 3rd ed. St. Louis: Mosby Inc.,2000.
Mastering Documentation, 2nd ed. Springhouse, Pennsylvania: Springhouse Corporation, 1999.
Katherine L. Hauswirth, APRN
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