For each of the qualities listed below, please describe the consequences if the quality is missing from the medical record?
The Medical Record is used for clinical communication and care planning. Health care companies, employers, payers and patients, use information in the medical record. It documents the basis for care and treatment of the patient. It must include documentation to support payment for services. It must protect the legal interests of the patient and the doctor. Finally, the medical record provides data usable in medical research.
Here is your list of factors and the consequences if they are missing from the medical record:
Accuracy: It goes without saying that accuracy is crucial. Incorrect information or data in the medical record can lead to treatment errors, patient harm and even death.
Accessibility: The medical record must be accessible to all members of the health care team in order for each team member to participate correctly in the care of the patient. It must also be available to the health insurance company to ensure proper payment for medial services.
Comprehensiveness: The medical record must be complete and comprehensive. It must reflect a full and thorough medical “work-up” of the patient, and show all needed supporting tests, X-rays and examinations so that another health care worker could, if necessary, determine the correct diagnosis and treatment. The medical record is the only permanent source of information about the evaluation, testing and treatment of the patient. Without a complete medical record, the medical examinations and tests lose their value.
Consistency: It is important for the practitioner to be consistent in her medical record keeping. This means that she creates a proper medical record as described herein for each and every patient encounter.
Currency: Medical records must be created at the time of patient encounter. It does no good to see and diagnose a patient without documenting the visit. For example, if a patient is examined and found to have a penicillin allergy, it is dangerous and unacceptable to fail to document this immediately on the patient chart.
Definition: This term is somewhat vague with respect to the medical record. Surely, however, it is important that descriptions and diagnoses are clearly defined in the medical record so that other practitioners can use the record to reach the correct conclusion about the patient’s condition and treatment.
Granularity: This term is not ordinarily considered a quality of the medial record.
Precision: Like definition, precision of terminology (and consistency thereof) should occur throughout the medical record.
Relevancy: The record should contain all information needed to establish and confirm the diagnosis and proper treatment of the patient. It should NOT contain irrelevant and extraneous material. Nor should the medical record contain subjective information about the patient that has nothing to do with her care. It should never contain personal, derogatory comments about the patient. Information that might infer that the physician is biased against the patient for some reason must be omitted.
Timeliness: See “currency” above.
Please see the reference for a treatise on Maintaining Accuracy and Compliance in the Medical Record.