A medical chart is a confidential document that contains detailed and comprehensive information on an individual and the care experience related to that person.
The purpose of a medical chart is to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement. The specific information contained in the chart is intended to provide a record of a person's clinical condition by detailing diagnoses, treatments, tests and responses to treatment, as well as any other factors that may affect the person's health or clinical state.
Every person who has a professional relationship with a health-care provider has a medical record. Because most people have such relationships with more than one health professional or caregiver, most people actually have more than one medical chart.
The terms medical chart or medical record are a general description of a collection of information on a person. 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 clearer documentation, enhanced access and searching, and more efficient storage and retrieval of individual records.
New uses of technology have also raised concerns about confidentiality. Confidentiality, or personal privacy, is an important principle related to the chart. Whatever system may be in place, it is essential that the health care provider protect an individual's privacy by limiting access only to authorized individuals. Generally, physicians and nurses write most frequently in the chart. Documentation by the clinician who is leading treatment decisions (usually a physician) often focuses on diagnosis and prognosis, while the documentation by members of the nursing team generally focuses on individual 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 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 a person 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 about institutional policies regarding chart access in order to ensure the privacy of personal records.
The medical record should be stored in a pre-designated, secure area and discussed only in appropriate and private clinical areas. All individuals have a right to view and obtain copies of their own records. 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 those cases in which individuals outside of the immediate care system must access chart contents, an individual or personal representative is asked to provide permission before records can be released. Individuals are often asked to sign these releases so that caregivers in new clinical settings may review their charts.
Thorough training is essential prior to independent use of the medical chart. Whenever possible, a new clinician should spend time reviewing the chart to get a sense of organization and documentation format and style.
Documentation in the medical record begins when an individual enters the care system, which may be a specific place such as a hospital or professional office, or a program such as a home health-care service. Frequently, a facility will request permission to obtain copies of previous records so that they have complete information on the person. Although chart systems vary from institution to institution, there are many aspects of the chart that are universal. Frequently used chart sections include the following:
- Admission paperwork. Includes legal paperwork such as a 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 an individual's medical history and physical examinations.
- Orders. Contains medication and treatment orders by the doctor, nurse practitioner, physician assistant, or other qualified health care team members.
- Medication record. Documents all medications 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 tracings or radiography images or summaries of test results.
- Progress notes. Includes regular notes on the individual's status by members of the interdisciplinary care team.
- Consultations. Contains notes from specialized diagnosticians or external care providers.
- Consents. Includes permissions signed by the individual for procedures, tests, or access to chart. May also contain releases such as the release signed by any person when leaving the facility against medical advice (AMA).
- Flow records. Tracks specific aspects of professional care that occur on a routine basis, using tables or in a chart format.
- Care plans. Documents treatment goals and plans for future care within a facility or following discharge.
- Discharge. Contains final instructions for the person and reports by the care team before the chart is closed and stored following discharge.
- Insurance information. Lists health-care benefit coverage and insurance provider contact information.
These general categories may be further divided by individual facilities for their own 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 (for instance, with large colored stickers or special chart sections) on the chart in order to communicate uniquely important information. It is important for health care providers to become familiar with the charting systems in place at their specific facilities or programs.
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 an individual's baseline, or status on admission or entry into an office or health care system; orders and treatments provided in response to specific problems; and individual responses. Another reason for the standard of clear documentation is the possibility that the record may be used in legal proceedings, when documentation serves as evidence in exploring and evaluating a person's care experience. When medical care is being referred to or questioned by the legal system, 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 the following:
- Date and time should be included on all entries into the record.
- A person's full name and other identifiers (i.e., medical record number, date of birth) should be included on all records.
- Continued records should be marked clearly (i.e., if a note is continued on the reverse side of a page).
- Each page of documentation should be signed.
- Blue or black non-erasable ink should be used on handwritten records.
- Records should be maintained in chronological order.
- Disposal or obliteration of any records or portions of records should be prevented.
- Documentation errors and corrections should be noted clearly, i.e., by drawing one line through the error and noting the presence of an error, and then initialing the area.
- Excess empty space on the page should be avoided. A line should be drawn through any unused space, the initial, time, and date included.
- Only universally accepted abbreviations should be used.
- Unclear documentation such as illegible penmanship should be avoided.
- Contradictory information should be avoided. For example, if a nurse documents that a person has complained of abdominal pain throughout a shift, while a physician documents that the person is free of pain, these discrepancies should be discussed and clarified. The resolution should be entered into the chart and signed by all parties involved in the disagreement.
- Objective rather than subjective information should be included. For example, personality conflicts between staff should not enter into the notes. All events involving an individual should be described as objectively as possible, i.e., describe a hostile person by simply stating the facts such as what the person said or did and surrounding circumstances or response of staff, without using derogatory or judgmental language.
- Any occurrence that might affect the person should be documented. Documented information is considered credible in court. Undocumented information is considered questionable since there is no written record of its occurrence.
- Current date and time should be used in documentation. For example, if a note is added after the fact, it should be labeled as an addendum and inserted in correct chronological order, rather than trying to insert the information on the date of the actual occurrence.
- Actual statements of people should be recorded in quotes.
- The chart shouldn't be left 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 a person's experience. In the critical care setting, flow records are often used to track frequent personal 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 comparisons. Flow records can also save time for a busy clinician by allowing for the completion of checklists versus requiring written narrative notes.
Narrative progress notes, while more time consuming, are often the best way to capture specific information about an individual. Some institutions require only charting by exception (CBE), which requires notes only for significant or unusual findings. 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 a person. Many facilities or programs require notes at regular intervals even when there is no significant occurrence, i.e., every nursing shift. Frequently used formats in individual notes include SOAP (subjective, objective, assessment, plan) notes. SOAP notes use an individual's subjective statement to capture an important aspect of care, follow with a key objective statement regarding the person's status, a description of the clinical assessment, and a plan for how to address individual problems or concerns. Focus charting and PIE (problem-intervention-evaluation) charting use similar systems of notes that begin with a particular focus such as a nursing diagnosis or an individual concern. Nursing diagnoses are often used as guides to nursing care by focusing on individual care-recipient needs and responses to treatment. An example of a nursing diagnosis is fluid volume for someone who is dehydrated. The notes would then focus on assessment for dehydration, interventions to address the problem, and a plan for continued
Current medical charts are maintained by members of the health care team and usually require clerical assistance such as a unit clerk in the hospital setting or records clerk in a professional office. No alterations should be made to the record unless they are required to clarify or correct information and are clearly marked as such. After discharge, the medical records department of a facility checks for completeness and retains the record. Similar checks may be made in professional office settings. Sometimes, the record will be made available in another format, i.e., recording paper charts on microfilm or computer imaging. Institutional policies and state laws govern storage of charts on- and off-site and length of storage time required.
A major potential risk associated with medical charts is breach of confidentiality. This must be safeguarded at all times. Other risks include loss of materials in a chart or incorrectly filing a chart so that subsequent retrieval is impeded or impossible.
All members of a health-care team require thorough understanding of the medical chart and documentation guidelines in order to provide competent 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 a specific legal case.
Morbidity and mortality rates
Medical charts are made of paper or other materials. They are subject to deterioration or loss. Transporting them may cause lifting injuries, but not lead to disease or death.
There are no alternatives for medical charts. Alternative mediums exist for paper records. These include fixing images on plastic media (photographs or x rays) or electronic storage. The latter can include magnetic tape or computer disks.
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L. Fleming Fallon, Jr, MD, DrPH
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
All members of a health-care team or individuals who render professional health-care services usually make entries into medical records. Healthcare records are maintained in hospitals or other clinical settings and professional offices. Insurance companies and corporations may maintain limited health-care records or obtain copies of records created by other health-care providers.
QUESTIONS TO ASK THE DOCTOR
- In a particular setting, who has the authority to make entries in a medical chart?
- Who has access to the chart?
- How is security maintained for medical records?