Articles: Medical Records
Physician office records: Are they complete?
 The
following article is modified from Starke, K. and Starke,
G. “Office-based Records”, in Iyer, P., Levin,
B., and Shea, M.A., (Editors) Medical
Legal Aspects of Medical Records, Tucson, Lawyers and
Judges Publishing Company, 2006.
Attorneys
often ask Med League to organize medical records for the
purposes of doing a medical summary or to send to an expert.
The question may arise: Are these records complete? There
are wide differences in how records are kept and supplied
to an attorney. Some physicians’ offices will yield
everything in the file, whereas others will decide what
the attorney (or patient) should receive. Knowing what should
be in the file enables Med League’s nurses to recognize
what is missing.
Office
records may span the lifetime of an individual, although
this is not common with today’s mobile society. Office
medical records are typically not as voluminous as hospital
or nursing home records. The method of organization for
the following sections is variable from office to office.
In addition, some physicians will keep laboratory, radiology,
and correspondence next to the corresponding office visit
note. The following list details components that may be
found within office records.
Initial intake form: This is a document
that is typically filled out by the patient and details
complaints and other illnesses. The intake form summarizes
current medications, allergies, past surgeries, previous
hospitalizations, prior illnesses, vaccination record, social
history, which includes employment, marital status, lifestyle
habits such as smoking, alcohol intake, seat belt usage,
exercise, the presence of advanced directives in place and
power of attorney. Also noted is family history including
the health status of parents and siblings or current illnesses
of these family members, and a check-off list of symptoms
previously or currently experienced.
Initial
history and physical: The physician performs a
detailed history and physical the first time the patient
is being seen.
Problem
list: Once the initial history is obtained, the
physician office will frequently make a separate and continually
updated list of medications, allergies, and vaccinations,
as well as a list of all chronic illnesses or conditions.
These are sometimes consolidated into one summary sheet
and kept highly visible on the left hand side of the patient
file as it is opened.
Physician
office notes of visits: Notes may be dictated and
transcribed, handwritten, documented in the form of reports
to a referring physician, or entered into an electronic
medical record. Data should include weight, blood pressure,
pulse, complaints, examination findings, diagnoses, and
treatment and plan for care, including prescriptions and
advice on when to return to the office. Physician assistants
and nurse practitioners may alternate with the physician
in seeing the patient and recording in the chart. Appointments
missed by the patient may be noted as “NS” (no
show), or “DNKA” (Did Not Keep Appointment.)
Laboratory,
radiology, EKG and other medical procedure results:
Test results should have some notation either on the test
report itself or within the physician office notes that
the results were reviewed by the physician, communicated
to the patient, and that follow-up was given to the patient,
if necessary, to further evaluate the results or monitor
the findings at a specific time interval. This can be accomplished
through a phone call, letter, or follow-up office visit.
Some physicians simply initial the test results. Routine
and normal results may be communicated to the patient by
the office staff following a specified office procedure.
Correspondence:
This section includes letters sent to and from the physician,
consultation notes with other physicians, outpatient services
such as physical therapy, and letters sent to or received
from the patient. It should also include email messages
to and from the patient.
Copies
of hospital records: Included are discharge summaries,
histories and physicals, operative reports, and consultations
from other physicians. Copies of hospital records are not
always included and may be incomplete if present.
Home
health care records: The office records may include
reports from the agency providing care under the direction
of the office. Records typically include the plan of care
and discharge summaries.
Phone
call records. These are frequently noted before
or after office visits to maintain an easily readable time
sequence of events. Phone message slips may be taped or
stapled to office records.
Billing
records: These documents may or may not be kept
within the body of the medical record and should be compared
with the dates of the office visits to see if all visits
are documented in the form of notes.
Prescriptions:
On occasion, copies of prescriptions for medications or
therapeutic treatments will be found within records.
Return
to work or excuse from work/school notes, and disability
records: Copies of these forms are kept in the
records.
Med
League’s legal nurse consultants have been asked to
transcribe difficult to read physician handwriting and to
provide an analysis of records that look
altered. Contact
us for further information about these services. See
also our new products: Detection
of Tampering with Medical Records Toolkit for Plaintiff
Attorneys, Legal Nurse Consultants, and Paralegals,
and Detection
of Tampering with Medical Records Toolkit for Administrators,
Risk Managers, and Defense Attorneys.
Learn
more about the text, Medical
Legal Aspects of Medical Records.
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to Medical Records articles.
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