Medical records should contain enough information to identify the patient, support a diagnosis, and justify treatment or care

As health care providers, we all have an ethical duty to preserve the confidentiality of information obtained from our patients during the course of care and treatment.

For centuries, confidentiality issues have been addressed: The Hippocratic Oath; the Florence Nightingale Pledge; the 1803 adoption of the American Medical Association’s Principle of Medical Ethics; the American Hospital Association for Patient Rights; state and federal laws; and the latest, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Though ethical principles are not law, the courts have regularly ruled such to be legal duties, requiring health care providers to preserve the confidentiality of patient information. Violation of these duties may result in a negligent act.

The purposes of medical records are to:

• serve as a basis for planning patient care and/or continuity in the evaluation of the patient’s condition and treatment;
• furnish documentation of the course of the patient’s medical evaluation, treatment, and change in his or her condition,
• document communication between all health care providers that provide or contribute to that patient’s care (for this reason, it is important to obtain all medical records from treating doctors or facilities that have treated the patient for the same presenting symptoms for which they came into your office); and
• help protect the legal interest of the patient.

In short, medical records are designed to provide a medical history, determine if past treatment has been effective, determine what other health care providers have done, and protect the health care provider from negligence issues if the duty to protect the patient’s rights has been violated. Not having all the medical records is a major issue in negligent cases.

Medical records should be kept on original paper and retained for a period of a mandatory 5 years, with statute of limitations at 7 years.

Who Has Access to Medical Records?
All patients have the right to access their own records and obtain copies of those records. In addition, the patient’s legal representative has the right to those records, as long as the patient has signed a release of records to accompany any request from the legal representative. Other health care providers have the right to the patient’s records if they are directly involved in the care and treatment of the patient. Care can be a referral to their office or joint care between you and another health care provider. Also, a competent adult appointed in writing by another competent adult (living will or health care surrogate), a parent of a minor, or a personal representative of an estate have access to a patient’s medical records.

All patients have the right to access their own records and obtain copies of those records by signing a release of records form. By doing this, you are protecting yourself from releasing medical records without a consent by the patient. These are other means by which medical records can be released:

1. To insurance carriers of the patient you are treating;
2. Subpoena;
3. Superconfidential records: Court order only, but must meet a strict need. There are also exceptions to this release;
4. Emergency medical treatment: Must attempt to get consent if you can; and
5. Unwed pregnant minor or minor mother may consent to treatment as it relates to her pregnancy or post-pregnancy only. For all other purposes, she is still a minor. (Check your particular state laws.)

What are the Requirements?
All states have similar and minimal record-compliance requirements. As part of the “confidentiality of medical records,” it is important to know what is required by law to be a part of your medical records or patient charts. State and federal laws exist concerning your patient charts and what is required to be in them. The following list will give you a guideline as to what is required:

• history, patient-intake form with basic information, chief complaints, and history of complaints as told by the patient, subjective complaints or presenting complaints; Make sure you have a place for the patient to sign the history or intake form. This form acts as a general consent to treat the patient.
• past and social history of the patient;
• diagnosis, impressions, and prognosis;
• review of symptoms;
• physical examination, and re-examinations (objective findings);
• any laboratory findings;
• x-ray reports; Be sure to read and initialize reports; signing charts attests to their accuracy and that you have reviewed them.
• diagnostic tests, impressions, and interpretations;
• prognosis notes; Include a signature of the doctor and date at the bottom of each completed page attesting to the record’s accuracy. Progress notes also justify care and establish medical necessity, and they should be written daily. Also, number the pages. If the progress notes are written by someone else, the DC must sign the notes within 7 days after the initial entry into the charts.
• document discharge of maximum medical improvement of the patient: reason, diagnosis, treatment, findings, and condition of the patient at the time of discharge;
• any other medical records from the patient regarding past care by other health care providers;
• any consultations to render an opinion—written or verbal—and any review of your medical charts or records;
• medical consents to treat explained to the patient by the doctor and signed by the patient. These are medical consent issues in negligent cases, and they can be tried and ruled upon separately (recent ruling by the Wisconsin Supreme Court); and
• notes of any health care provider that assumes care at any time.

Medical records should contain enough information to identify the patient, support a diagnosis, and justify treatment or care. They should document the course of treatment and the results of that treatment, including history, examination, test results, reports, and signed and initialized records. Maintain theses records in a legible and accurate manner.

Keep in mind that lack of documentation or failure to document your charts with essential information falls below the standard of care. Failure to document is one of the most common errors and fraud issues that DCs face. In addition, falling below the standard of care may become a negligence issue if a patient is injured or perceives an injury and sues you.

Your patient chart should provide a reason for treatment. Missing documentation equals “no treatment.”

Correctly documenting your patient charts and medical records is the best way to ensure that an investigator doesn’t come knocking at your door. Remember that all patients have the right to access their own records and obtain copies of those records. Be aware of the criteria for medical necessity and the need for treatment. Document your patient records properly and within the minimum standards set forth by statutes or your board. CP

Kenneth Ross, DC, JD, is a former criminal law enforcement officer with 18 years of experience. He teaches and specializes in tort law, negligence, risk management, medical records, expert witness, and criminal issues involving practice boundaries. He practices chiropractic in Orlando, Fla. He can be reached at (866) 225-5055 or via email at backdoc2@prodigy.net.