Physician records can be pivotal in nursing or medical liability cases. These records may be obtained in the same way as hospital records.

Nursing documentation in physician practices and clinics should follow guidelines for legally appropriate charting. Nurses are not employed in all physician practices; however, the rules of documentation which apply to them still apply to other practice staff (technicians, therapists, advanced practice nurses, and others) who are required to chart in those practices.

The components of a physician practice chart are usually more limited than hospital or nursing home records. They may include:

1. A face sheet which contains patient demographics such as name, age, gender, insurance coverage, and possibly working diagnoses
2. A cover sheet which tracks medications the patient is on (this page may also be found in other areas of the chart). If no centralized tracking of the patient’s medications is found on a practice or clinic record, the chart should be carefully reviewed for possible medication error.
3. Progress notes, which may include notations by physicians, nurses, and other clinical professionals who work in the practice. These notes need to be dated and signed just like those in hospital charts, unless there is only one person who documents in this area. If there is only one person using the progress notes, then this person’s notes must be dated.
4. Laboratory and other test results. Test results should be initialed by the physician or nurse practitioner to note that they have been reviewed. If no notation indicating review is found, the result may have been filed in the chart without the physician seeing it.
5. Reports from consultants, copies of office notes from visits to other providers; these reports should be handled in the same way as test results.
6. Miscellaneous – insurance cards, return to work notes, billing.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.