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The medical record of an individual patient serves numerous functions. Ideally, the record should provide a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities (such as hospitals). The medical record also serves as the basis for a variety of financial, legal, and administrative functions including the documentation for both professional and facility fee reimbursement, quality and safety assessments (including pay for performance), malpractice litigation and disability determinations, and community-based care and public health initiatives.

Currently, the medical record of an individual patient is fragmented, with various pieces shared only sometimes among numerous providers. Hospitalists typically care for a patient during a single episode of facility-based care. Fortunately, the proliferation, adoption, and increasing interoperability of electronic medical records (EMRs), and their evolution into personalized health records, holds promise for consolidation and availability of all relevant clinical information to each provider participating in the care of a single patient.

Some General Principles

This chapter focuses upon the documentation requirements incumbent upon hospitalists for professional fee billing of their clinical services. Some general principles of physician documentation warrant discussion despite this focus, and apply to both paper and electronic medical records.

The documentation of physician services should always comprise the essential components of a patient's chief complaint, history, physical examination, and medical decision making. The concerns of both patient and provider should be clearly recorded, including expectations (realistic or not) and satisfaction (and dissatisfaction). All diagnostic test orders and results should reside in the chart, as well as documentation of various specific services (eg, physical, occupational, speech, or rehabilitation therapy; home health services, durable medical equipment needs, and social work evaluations).

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Practice Point
  • The documentation of physician services should always comprise the essential components of a patient's chief complaint, history, physical examination, and medical decision making. The concerns of both the patient and provider should be clearly recorded, including expectations (realistic or not) and satisfaction (dissatisfaction).

Corrections

At some point in time, every medical record requires a correction. In a paper document, draw a single line through the inaccurate portion and write a correction nearby, dating and signing the revision. The original entry thereby remains legible for future reference. For example, consider misidentification of a right swollen knee joint, when actually it is on the left: when the physician recognizes the mistaken documentation, the right side should have a single line drawn through it (ie, overstrike text) and a note written nearby indicating that the left side is the accurate side. Sign and date these changes on the day of correction. Methods and appearances of corrections and amendments in electronic medical records continue to evolve, but all incorporate password-protected signatures with electronic date- and time-stamped entries.

Late-Entry Documentation

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