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Healthcare 101: Basics of Medical Records Documentation

Updated: Feb 20, 2022

A patient’s medical record is like a roadmap for his or her care. However, it also fills the same role for a clinic’s office staff by providing the patient information needed for billing, whether third-party insurers, self-pay, or a combination of both.

But patient information can change as quickly as their lives do. People find new jobs, move to new towns, change prescriptions, get married or divorced, and so on. That’s why it is essential for medical practices to regularly check essential patient information to capture any changes that may affect treatment and the payment process.

While there will be patients who resent or get annoyed at being asked the same questions at each visit, that doesn’t mean nothing has changed since their last visit. If you let the review of patient information slide, you may end up with incorrect billing, returned mail and more.

Clinic-ology knows that best practices point to healthcare practices setting policies for updating patient demographic information, including how often and a checklist of questions. A quick “Anything new or changed?” when an appointment is made, during pre-registration, and at check-in may be an informal and friendly way to ask but can fail to capture changes. What’s important from a medical perspective may not be so from the patient’s.

In addition, many practices also make it a policy to annually photocopy patient insurance cards and identification to keep records up-to-date, either at the start of the year or at the patient’s annual checkup. This is often done at the same time HIPAA and consent forms are signed.

Clinic-ology recommends that these five elements in a patient’s medical record should be regularly checked for updates or a photocopy:

1. Patient demographics.

  • Physical, mailing and email address.

  • Home and mobile phone numbers.

  • Sex, age, birthday and ethnicity.

  • Occupation and employer name, address and phone number.

  • Spouse or partner name and contact information.

2. Financial information.

  • Insurance payer name, address and phone number.

  • Subscriber name.

  • Policy number.

  • Responsible party name, address and phone number.

  • Responsible party employer, occupation and employer phone number.

  • Patient relationship to the insured.

3. Release of information. A valid authorization to release protected health information includes:

  • Identity verification such as a driver’s license.

  • A description of the information to be used or disclosed.

  • The name of the person or organization authorized to disclose the information.

  • The name of the person or organization that the information is to be disclosed.

  • Signature of the person authorized to release the information.

4. HIPAA Notice of Privacy Practices. Required by federal rule, HIPAA gives patients the right to be informed about their privacy rights as they relate to protected health information.

  • Have patient update HIPAA notice annually.

5. Consent and authorization forms. Treatment and treatment plans that go beyond routine medical procedures require the physician to disclose as much information as possible. This is so the patient can make an informed decision about care and should include:

  • Diagnosis and chances of recovery.

  • Recommended course of treatment.

  • Risks and benefits involved in treatment.

  • Risks if no treatment is taken.

  • Probability of success if treatment is taken.

  • Recovery challenges and length of time.

  • Assignment of benefits: the patient or other person responsible authorizes their health insurance company to make payments directly to the physician, medical practice or hospital for the treatment received.

Documenting patient treatment in medical records

Medical records contain much more than demographic information and forms. Medical records also provide the history of patient care. So, consistently documenting visits, diagnoses, treatments and outcomes is crucial to quality patient care.

Medical notes and reports should be clear, concise and legible and include information about assessments, action taken, outcomes, reassessment processes as needed, risks, complications and changes.

A medical record using best practices will also contain:

1. Medication list.

  • Prescription and nonprescription medications, including dose, method of intake, and schedule.

2. Treatment history.

  • Chief complaints.

  • History of illness.

  • Vital signs.

  • Physical examination.

  • Surgical history.

  • Obstetric history.

  • Medical allergies.

  • Family history.

  • Immunization history.

  • Habits such as exercise, diet, alcohol intake, smoking, and drug use/abuse.

  • Developmental history.

3. Progress notes. This includes new information and changes during patient treatment and are written by all members of the treatment team. Information includes:

  • Observations of the patient’s physical and mental condition.

  • Sudden changes in the patient’s condition.

  • Vital signs at certain intervals.

  • Food intake.

  • Bladder and bowel functions.

4. Physician orders and prescriptions.

  • Physician’s orders for the patient to receive testing, procedures or surgery including directions to other members of the treatment team.

  • Prescriptions for medications and medical supplies or equipment for the patients home use.

  • Consults: Receive opinions from consulting physicians.

  • Lab Reports: Record of findings from lab testing.

5. Radiology and other test reports.

6. Nursing notes. These are separate from the physician notes and includes:

  • Patient assessment.

  • Processes.

  • Intervention.

  • Evaluation.

Medical records can be lengthy and complex but are critical to the medical practice and the patient. At Clinic-ology, we use best practices in our training, consulting and workshops to bring the skills needed for today’s healthcare professionals to the medical field.

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